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Alignment Health ESRD Balance (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Alignment Health ESRD Balance (HMO C-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Alignment Health ESRD Balance (HMO C-SNP) in 2025, please refer to our full plan details page.
Alignment Health ESRD Balance (HMO C-SNP) is a HMO C-SNP plan offered by Alignment Healthcare USA, LLC available for enrollment in 2025 to people living in Los Angeles and Orange. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Alignment Health ESRD Balance (HMO C-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Alignment Health ESRD Balance (HMO C-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Alignment Health ESRD Balance (HMO C-SNP).
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 ESRD Balance (HMO C-SNP), 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.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 $1499.00 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 ESRD Balance (HMO C-SNP) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay varying copays or coinsurance amounts depending on the drug tier and pharmacy used. For example, preferred generic drugs have no copay at standard mail, while standard generic drugs have a $40 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Alignment Health ESRD Balance (HMO C-SNP) plan offers a variety of benefits, including inpatient and outpatient services, with copays varying by service. Emergency services have a $75 copay, and ambulance services have a $100 copay. Primary care, preventive services, hearing, vision, dental, and home health services are also covered, with specific copays, coinsurance, and limitations for each. Additional benefits include coverage for medical equipment, dialysis, and home infusion services, with varying copays and coinsurance. The plan also provides coverage for skilled nursing facilities, and cardiac rehabilitation services, with specific requirements for prior authorization and referrals. Other covered services include OTC items with a monthly maximum benefit, and a personalized health risk screening benefit.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for acute and psychiatric inpatient hospital stays. For Inpatient Hospital Psychiatric, there is a $120 copay for days 1-10, and no copay for days 11-90. Additional days for Inpatient Hospital Psychiatric are covered up to 40 days per benefit period, while non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered by the Alignment Health ESRD Balance (HMO C-SNP) plan, including all outpatient hospital services, ambulatory surgical center (ASC) services, and outpatient substance abuse services. Outpatient hospital services have a $50 copay, and individual and group sessions for outpatient substance abuse have a $20 copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Alignment Health ESRD Balance (HMO C-SNP) plan, requiring prior authorization and a doctor referral. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Alignment Health ESRD Balance (HMO C-SNP) plan. Medicare-covered ground and air ambulance services each have a $100 copay, while transportation services to any health-related location are not covered, but transportation services to a plan-approved health-related location are covered for up to 42 one-way trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered by the Alignment Health ESRD Balance (HMO C-SNP) plan. Emergency Services have a $75 copay, while all other services in this benefit have no copay and no coinsurance, with a maximum plan benefit coverage of $7,500 for Worldwide Emergency Services. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care for Alignment Health ESRD Balance (HMO C-SNP) covers Primary Care Physician Services, Occupational Therapy, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy, Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Chiropractic Services, and Individual and Group Sessions for Mental Health Specialty Services are covered but require prior authorization and a doctor referral. Individual and Group Sessions for Psychiatric Services have a $40 copay, and Opioid Treatment Program Services have a 20% coinsurance.
Preventive Services See details
The Alignment Health ESRD Balance (HMO C-SNP) plan covers preventive services, including annual physical exams, glaucoma screenings, and diabetes self-management training, among others. In-Home Support Services, Support for Caregivers of Enrollees, and Fitness Benefit are also covered. However, several services, such as Health Education, and Counseling Services are not covered.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids, each covered once per year. Prescription hearing aids and OTC hearing aids are not covered.
Vision Services See details
The Alignment Health ESRD Balance (HMO C-SNP) plan covers vision services including routine eye exams, eyewear, contact lenses, eyeglasses (lenses and frames), and upgrades, with no deductible. Routine eye exams are limited to one per year. Eyewear has a combined maximum benefit of $200.00 every year, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are each limited to one per year.
Dental Services See details
Dental Services are covered, including oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments. Restorative services have a copay of $20-$400, endodontics has a copay of $25-$350, periodontics has a copay of $15-$550, prosthodontics (removable) has a copay of $20-$570, prosthodontics (fixed) has a copay of $40-$400, and oral and maxillofacial surgery has a copay of $25-$250. Adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, are covered with prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered with prior authorization and a doctor's referral, and the coinsurance is 10%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 0-20% coinsurance and no copay, and Prosthetic Devices and Medical Supplies with 20% coinsurance and no copay. Diabetic Equipment is covered, but Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Alignment Health ESRD Balance (HMO C-SNP) plan. Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, and Outpatient X-Ray Services are not covered, while Therapeutic Radiological Services are covered with a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Alignment Health ESRD Balance (HMO C-SNP) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization and a referral.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, with prior authorization and a doctor referral required. For days 1-20, there is no copay, and for days 21-100, the copay is $50. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Alignment Health ESRD Balance (HMO C-SNP) plan covers Over-the-Counter (OTC) Items with a maximum benefit of $100.00 every month, and a $75 copay for Other 1 benefits, which includes Personalized Health Risk Screening, up to a maximum of $200.00 every two years. Acupuncture, 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, Self-Directed Personal Assistance Services are not covered.
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