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Astiva Health Savings Plan - NorCal (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Astiva Health Savings Plan - NorCal (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 - NorCal (HMO) in 2025, please refer to our full plan details page.
Astiva Health Savings Plan - NorCal (HMO) is a HMO plan offered by Astiva Health Holdings Incorporated available for enrollment in 2025 to people living in Counties: SCL. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Astiva Health Savings Plan - NorCal (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 - NorCal (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 - NorCal (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 $174.40. 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 $3000.00 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:
Sign up for Astiva Health Savings Plan - NorCal (HMO)
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Drug Coverage
The Astiva Health Savings Plan - NorCal (HMO) has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay varying copays or coinsurance amounts depending on the drug tier and pharmacy. For example, standard generic drugs have a $40 copay, while preferred brand drugs have a $95 copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. However, you may still be responsible for costs associated with excluded drugs covered under any enhanced benefit.
Additional Benefits
The Astiva Health Savings Plan - NorCal (HMO) offers a range of benefits with varying cost-sharing. Inpatient hospital stays have copays depending on the length of stay, while outpatient services have copays for specific services like outpatient hospital services and ambulatory surgical center services. Emergency services have a copay, and primary care visits have copays for certain services. Preventive services have no copay, and vision services include routine eye exams and eyewear benefits. Dental services cover a variety of services with coinsurance or maximum plan benefits. The plan also covers home health services and skilled nursing facility stays with no copay for the initial days, as well as over-the-counter items with no copay.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, there is no copay for days 1-4 and days 16-90, and a $200 copay for days 5-15, while additional days 91-150 have no copay. For Inpatient Hospital Psychiatric, there is a $125 copay for days 1-4, a $200 copay for days 5-15, and no copay for days 16-60; additional days 91-150 have no copay. Non-Medicare-covered stays and upgrades for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a $200 copay, ambulatory surgical center services with a $100 copay, outpatient substance abuse services with a $40 copay for both individual and group sessions, and outpatient blood services. Observation services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered with a $80 copay, and requires both prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Astiva Health Savings Plan - NorCal (HMO). Ground Ambulance Services have a $160 copay, while Air Ambulance Services have a 20% coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered. Emergency Services have a $90 copay, and Urgently Needed Services have a $25 copay, while all other services have no copay and no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care includes coverage for Primary Care Physician Services, Chiropractic 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. Chiropractic Services have a $15 copay, Occupational Therapy Services, Individual Sessions for Mental Health Specialty Services, Group Sessions for Mental Health Specialty Services, Individual Sessions for Psychiatric Services, Group Sessions for Psychiatric Services, and Opioid Treatment Program Services have a $25 copay, and Physical Therapy and Speech-Language Pathology Services have a $25 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Astiva Health Savings Plan - NorCal (HMO) covers preventive services, including Medicare-covered preventive services, with no copay. Annual physical exams, health education, in-home safety assessments, Personal Emergency Response Systems (PERS), Medical Nutrition Therapy (MNT), post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, 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. The plan also covers kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit, all requiring prior authorization.
Hearing Services See details
Hearing Services are partially covered by the Astiva Health Savings Plan - NorCal (HMO), but Routine Hearing Exams, Fitting/Evaluation for Hearing Aid, all types of Prescription Hearing Aids, and OTC Hearing Aids are not covered. There is no deductible for covered services.
Vision Services See details
Vision services include routine eye exams, with one exam covered every year, and eyewear benefits that include contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. The plan covers up to $125.00 combined maximum for all eyewear every year.
Dental Services See details
Dental services include coverage for Medicare Dental Services with 20% coinsurance, Other Dental Services with a $250 maximum plan benefit every three months, Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, and Other Preventive Dental Services. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics, removable, Implant Services, Prosthodontics, fixed, and Oral and Maxillofacial Surgery are also covered. Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Astiva Health Savings Plan - NorCal (HMO) and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, while Other Medicare Part B Drugs and Medicare Part B Chemotherapy/Radiation Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered with prior authorization and a doctor referral. The plan has a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits are covered under the Astiva Health Savings Plan - NorCal (HMO), including Durable Medical Equipment (DME) with a coinsurance between 0% and 20% and no copay. Prosthetics/Medical Supplies and Diabetic Equipment are also covered, with coinsurance of 20% for Medicare-covered Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Astiva Health Savings Plan - NorCal (HMO), but Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. Diagnostic Radiological Services have a copay of up to $75, and Therapeutic Radiological Services have a coinsurance of 20%.
Home Health Services See details
Home Health Services are covered by the Astiva Health Savings Plan - NorCal (HMO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization and referral are required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Astiva Health Savings Plan - NorCal (HMO). Prior authorization and a doctor's referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Astiva Health Savings Plan - NorCal (HMO). There is no copay for days 1-20, and a $214 copay per day for days 21-100. Additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services include coverage for over-the-counter (OTC) items, with no copay or coinsurance, but does not cover acupuncture, 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, or Self-Directed Personal Assistance Services.
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