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Alignment Health smartHMO (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Alignment Health smartHMO (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Alignment Health smartHMO (HMO) in 2025, please refer to our full plan details page.
Alignment Health smartHMO (HMO) is a HMO plan offered by Alignment Healthcare USA, LLC available for enrollment in 2025 to people living in LA, OC, SD, SB, RV. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Alignment Health smartHMO (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 Alignment Health smartHMO (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 Alignment Health smartHMO (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 $2499.00 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 Alignment Health smartHMO (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay varying copays or coinsurance depending on the drug tier and pharmacy. For example, you'll pay no copay for preferred generic drugs at a standard pharmacy, a $30 copay for standard generic drugs, and a $100 copay for preferred brand drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. If you qualify for the low-income subsidy, you may have reduced premium costs.
Additional Benefits
The Alignment Health smartHMO (HMO) plan offers a range of benefits with varying costs. This plan includes coverage for inpatient and outpatient services, with copays ranging from $0 to $120, depending on the service. It also provides coverage for primary care, preventive services, vision, dental, and hearing services, with specific copays and limitations on certain services. Additional benefits include ambulance services, emergency services, and home health services, with specific copays and coinsurance. The plan covers services like home infusion, dialysis, and medical equipment, often with coinsurance requirements. However, it's important to note that some services, such as certain therapies, dental, and vision, may have coverage limits or require prior authorization.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with some services not usually covered by Medicare plans. Inpatient Hospital Psychiatric has a copay of $120 for days 1-10, and no copay for days 11-90, while additional days are covered up to 40 days.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a $100 copay, Ambulatory Surgical Center (ASC) services with a $50 copay, and outpatient substance abuse services with a $35 copay for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization and a doctor referral. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Alignment Health smartHMO (HMO) plan. Ground ambulance services have a $100 copay, while air ambulance services have a $200 copay, and there is no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services has a $70 copay, and no coinsurance. Worldwide Emergency Transportation is not covered. Worldwide Emergency Services has a maximum plan benefit coverage of $25,000.
Primary Care See details
The Alignment Health smartHMO (HMO) plan covers Primary Care services including Primary Care Physician Services, Chiropractic Services with a $10 copay, Occupational Therapy Services with no copay or coinsurance, Physician Specialist Services with a $5 copay, and Mental Health Specialty Services with a $10 copay for individual and group sessions. This plan also covers Psychiatric Services with a $20 copay for individual and group sessions, Physical Therapy and Speech-Language Pathology Services with no copay or coinsurance, and Opioid Treatment Program Services with a 20% coinsurance. Additional Telehealth Benefits are also covered. Podiatry Services are not covered.
Preventive Services See details
Preventive services, including annual physical exams, are covered by the Alignment Health smartHMO (HMO) plan. Additional preventive services include Personal Emergency Response System (PERS) and Fitness Benefit. Health Education, In-Home Safety Assessment, 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 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 covered services include Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas (prior authorization required), Digital Rectal Exams, and EKG following Welcome Visit.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids, each covered for one visit per year, as well as hearing exams, with no copay or coinsurance. Prescription hearing aids and OTC hearing aids are not covered.
Vision Services See details
The Alignment Health smartHMO (HMO) plan covers vision services, including routine eye exams once per year. Eyewear, including contact lenses, eyeglasses (lenses and frames), and eyeglass frames are covered, with a maximum benefit amount, and upgrades are not covered.
Dental Services See details
Dental Services include coverage for oral exams with a $10 copay, dental x-rays with a $30 copay, teeth cleanings with a $20 copay, and fluoride treatments with a $10 copay. Restorative Services have a copay between $20 and $400, endodontics have a copay between $25 and $350, periodontics have a copay between $15 and $550, removable prosthodontics have a copay between $20 and $570, prosthodontics, fixed has a copay between $40 and $400, and oral and maxillofacial surgery has a copay between $25 and $250. Orthodontic services are not covered, and adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Alignment Health smartHMO (HMO) plan and require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Alignment Health smartHMO (HMO) plan, with no copay for Durable Medical Equipment (DME), Prosthetics/Medical Supplies - Non-Medicare benefit, and Diabetic Therapeutic Shoes/Inserts, but with a 20% coinsurance. Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Alignment Health smartHMO (HMO) plan. There is no copay for any of the covered services, but some services are not covered including Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, and Outpatient X-Ray Services. Therapeutic Radiological Services are covered with a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Alignment Health smartHMO (HMO) plan with no copay or 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 generally covered, but not in practice as none of the sub-services are covered. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Alignment Health smartHMO (HMO) plan, but require prior authorization and a doctor's referral. The plan has a copay of $20 for days 1-20 and $100 for days 21-100. Additional days beyond Medicare-covered, and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are not covered by the Alignment Health smartHMO (HMO) plan, as acupuncture, 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. Digital Health Technology Support is covered.
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