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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 2026, 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 2026.
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 $164.90. 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 features an Enhanced Alternative drug benefit with no prescription drug deductible. During the initial coverage phase, you will pay no copay for Tier 1 preferred generic drugs through standard retail pharmacies or standard mail order. For other drug tiers, standard costs include a $30 copay for Tier 2 standard generics, a $100 copay for Tier 3 preferred brands, a $5 copay for Tier 5 specialty drugs, and a 33% coinsurance for Tier 4 non-preferred drugs. These copayments and coinsurance rates apply until your total drug costs reach $2,100. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Alignment Health smartHMO (HMO) plan features comprehensive coverage with no copay for preventive services, urgent care, and routine vision exams. Specialist visits are highly affordable with a low $5 copay and no coinsurance, while emergency room visits require a $70 copay. Outpatient hospital visits and ambulance services are also covered with fixed copays and no coinsurance, making everyday healthcare costs predictable. For ancillary care, members enjoy routine dental and vision exams with no copay, alongside a $200 annual allowance for eyeglasses. However, certain specialized services like dialysis, medical equipment, and therapeutic radiology require a 20% coinsurance with no copay. Additionally, inpatient psychiatric stays and skilled nursing facility care are covered with daily copays and no coinsurance.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by Alignment Health smartHMO (HMO), as upgrades and non-Medicare-covered stays are excluded from coverage. Covered inpatient psychiatric stays require a $120 copay for days 1 through 10, no copay for days 11 through 90, and no coinsurance, with doctor referrals and prior authorization required.
Outpatient Services See details
Alignment Health smartHMO (HMO) covers outpatient services with no coinsurance, including outpatient hospital visits for a $100 copay and ambulatory surgical center services for a $50 copay. Outpatient substance abuse sessions require a $35 copay with no coinsurance, while outpatient blood services are covered with no deductible, no copay, and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Alignment Health smartHMO (HMO) with a $55.00 copay and no coinsurance. Prior authorization and a doctor referral are required to receive these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by the Alignment Health smartHMO (HMO) plan, which features a $100 copay for ground ambulance services and a $200 copay for air ambulance services, with no coinsurance for either. Transportation services to plan-approved health-related locations and any health-related locations are not covered.
Emergency Services See details
Alignment Health smartHMO (HMO) covers emergency services with a $70 copay and no coinsurance, which is waived if you are admitted to the hospital within 48 hours. Urgently needed services are available with no copay and no coinsurance, while worldwide emergency services are partially covered up to a $25,000 maximum limit, excluding worldwide emergency transportation.
Primary Care See details
Primary Care benefits are partially covered by Alignment Health smartHMO (HMO), as podiatry services and routine chiropractic care are not covered. Covered services include specialist visits for a $5 copay, mental health sessions for a $10 copay, and psychiatric services for a $20 copay, all with no coinsurance, while opioid treatment requires 20% coinsurance with no copay.
Preventive Services See details
Preventive services are partially covered by Alignment Health smartHMO (HMO), which offers Medicare-covered preventive care, annual physical exams, and select screenings with no copay and no coinsurance. However, the plan does not cover health education, in-home safety assessments, medical nutrition therapy, medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, remote access, bathroom safety, or counseling.
Hearing Services See details
Hearing services are covered by Alignment Health smartHMO (HMO), offering one routine hearing exam and one fitting evaluation per year with no deductible. Although some services are covered, prescription hearing aids—including all types, inner ear, outer ear, and over the ear—as well as over-the-counter hearing aids are not covered in practice.
Vision Services See details
Vision Services are partially covered by the Alignment Health smartHMO (HMO) with no deductibles, copays, or coinsurance, including one routine eye exam per year, a $100 annual limit for contact lenses, and a $200 annual limit for eyeglasses, lenses, and frames. Eyewear upgrades are not covered under this plan.
Dental Services See details
Dental services are partially covered by Alignment Health smartHMO (HMO), offering preventive care such as exams and cleanings with no copay or coinsurance. Covered comprehensive services require copays ranging from $15 to $570 and no coinsurance, while adjunctive general services, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Alignment Health smartHMO (HMO) with prior authorization, although Part D home infusion drugs are not covered. Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs require no copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Alignment Health smartHMO (HMO) with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive these services.
Medical Equipment See details
Alignment Health smartHMO (HMO) partially covers medical equipment with a 20% coinsurance and no copay, though prior authorization is required. While durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes are covered, diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Alignment Health smartHMO (HMO) partially covers Diagnostic and Radiological Services, offering therapeutic radiological services with no copay and a 20% coinsurance. Diagnostic procedures and tests, lab services, diagnostic radiological services, and outpatient X-ray services are not covered.
Home Health Services See details
Home Health Services are covered under the Alignment Health smartHMO (HMO) plan, requiring prior authorization and a doctor referral to access care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by Alignment Health smartHMO (HMO), as none of the sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are covered in practice.
Skilled Nursing Facility (SNF) See details
Alignment Health smartHMO (HMO) partially covers Skilled Nursing Facility (SNF) services, requiring prior authorization and a doctor referral, though additional days beyond Medicare-covered care are not covered. Covered stays require a $20 copay with no coinsurance for days 1 through 20, and a $100 copay with no coinsurance for days 21 through 100.
Other Services See details
Alignment Health smartHMO (HMO) partially covers Other Services, providing Digital Health Technology Support with no maximum benefit limit, though specific copay and coinsurance amounts are not specified. Sub-services such as Acupuncture, Over-the-Counter (OTC) Items, Meal Benefits, and Dual Eligible SNPs with Highly Integrated Services are not covered.
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