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Astiva Health Savings Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Astiva Health Savings Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Astiva Health Savings Plan (HMO) in 2025, please refer to our full plan details page.
Astiva Health Savings Plan (HMO) is a HMO plan offered by Astiva Health Holdings Incorporated available for enrollment in 2025 to people living in Counties: OC, LA, RIV, SB, SD. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Astiva Health Savings Plan (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Astiva Health Savings Plan (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Astiva Health Savings Plan (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $174.70. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $2700.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Astiva Health Savings Plan (HMO) has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay for your prescriptions depending on the drug tier and the pharmacy you use. For example, you will pay a $12 copay for preferred generic drugs at a standard or mail-order pharmacy, while specialty tier drugs have no copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Astiva Health Savings Plan (HMO) offers comprehensive coverage with a variety of benefits. This plan includes inpatient hospital care with no copay for most days, outpatient services with varying copays, and partial hospitalization with an $80 copay. Emergency and urgent care services have a copay, and ambulance services have a copay or coinsurance. This plan also covers primary care, preventive services, hearing, vision, and dental services, with specific copays, coinsurance, and maximum benefits. Additional benefits include home infusion, dialysis, medical equipment, diagnostic services, home health, cardiac rehabilitation, and skilled nursing facility care with varying cost-sharing. The plan also includes acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including services not usually covered by Medicare plans. For Inpatient Hospital-Acute, you'll pay no copay for days 1-5, a $200 copay for days 6-15, and no copay for days 16-90; additional days 91-150 have no copay. Inpatient Hospital Psychiatric services have a $125 copay for days 1-5, a $200 copay for days 6-15, and no copay for days 16-60; additional days 91-150 have no copay. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient services include outpatient hospital services with a $200 copay, observation services, ambulatory surgical center services with a $75 copay, outpatient substance abuse services with a $15 copay for individual and group sessions, and outpatient blood services. Prior authorization and a doctor referral are required for some outpatient services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Astiva Health Savings Plan (HMO) with prior authorization and a doctor referral. You will have to pay a copay of $80 for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services include coverage for ground ambulance services with a $150 copay, and air ambulance services with 20% coinsurance. Transportation Services to any health-related location are covered for up to 12 one-way trips per year, using bus/subway or medical transport. Transportation Services to plan-approved health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered under the Astiva Health Savings Plan (HMO). Emergency Services have a $125 copay and no coinsurance, while Urgently Needed Services have no copay or coinsurance. Worldwide Emergency Services has a maximum benefit of $50,000, and Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic Services have a $15 copay, but routine care is not covered. Mental Health and Psychiatric individual and group sessions have a $25 copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, Alternative Therapies with 48 visits, Therapeutic Massage with 48 sessions, and Fitness Benefit for Memory Fitness. Annual Physical Exams, Health Education, In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. Other preventive services, including Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, are covered with prior authorization.
Hearing Services See details
Hearing Services are partially covered by the Astiva Health Savings Plan (HMO), but Routine Hearing Exams, Fitting/Evaluation for Hearing Aids, Prescription Hearing Aids (all types, inner ear, outer ear, and over the ear), and OTC Hearing Aids are not covered. There is no deductible for Hearing Exams.
Vision Services See details
The Astiva Health Savings Plan (HMO) covers vision services, including routine eye exams with one visit per year, and eyewear with a combined maximum benefit of $125 every two years. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Astiva Health Savings Plan (HMO) offers dental services including Medicare Dental Services with 20% coinsurance, other dental services with a $250 maximum benefit every three months, and coverage for oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), implant services, and oral and maxillofacial surgery with varying copays. Maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Astiva Health Savings Plan (HMO). You will pay a 20% coinsurance, and prior authorization and a doctor referral are required.
Medical Equipment See details
Medical equipment benefits are covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance between 0% and 20%, while Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts each have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Radiological Services with a copay of up to $75 and Therapeutic Radiological Services with 20% coinsurance. Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by the Astiva Health Savings Plan (HMO) with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. This benefit requires both authorization and a referral.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Astiva Health Savings Plan (HMO), but the specific services of Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Astiva Health Savings Plan (HMO), requiring prior authorization and a doctor's referral. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes acupuncture, with a limit of 48 treatments per year, and over-the-counter items. Meal benefits, dual eligible SNPs with highly integrated services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, case management (long term care), institution for mental disease services for individuals 65 or older, services in an intermediate care facility for individuals with intellectual disabilities, case management, tobacco cessation counseling for pregnant women, freestanding birth center services, respiratory care services, family planning services, nursing home services, home and community based services, personal care services, and self-directed personal assistance services are not covered.
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