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Alignment Health Balance (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Alignment Health 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 Balance (HMO C-SNP) in 2026, please refer to our full plan details page.
Alignment Health 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 2026.
It's important to know that Alignment Health 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 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 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 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 Balance (HMO C-SNP) plan features an Enhanced Alternative drug benefit with no prescription drug deductible. During the initial coverage phase, which lasts until total drug costs reach $2,100, there is no copay for Tier 1 preferred generic drugs at standard pharmacies and through standard mail. For other tiers at standard pharmacies or standard mail, you will pay a $40 copay for Tier 2 standard generics, a $100 copay for Tier 3 preferred brands, 33% coinsurance for Tier 4 non-preferred drugs, and a $5 copay for Tier 5 specialty drugs. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for covered Part D prescription drugs. Additionally, beneficiaries who qualify for the low-income subsidy, also known as Extra Help, can have their Part D premium reduced to $0.
Additional Benefits
The Alignment Health Balance (HMO C-SNP) plan offers robust coverage with predictable out-of-pocket costs, featuring no copays for preventive services, routine dental cleanings, and urgent care. For emergency situations, members pay a $75 copay with no coinsurance, while outpatient hospital services require a $50 copay. Inpatient psychiatric stays are covered with a $120 daily copay for days 1 through 10 and no copay for days 11 through 90. Additional perks include no-copay routine vision and hearing exams, a $200 annual eyewear allowance, and up to 42 one-way trips for approved medical transportation. While cardiac rehabilitation and diabetic supplies are not covered, the plan features no copays for home health services and durable medical equipment, which carries a 0% to 20% coinsurance. Additionally, skilled nursing facility stays require no copay for the first 20 days and a $50 daily copay for days 21 through 100.
Inpatient Hospital See details
Inpatient hospital care is partially covered by Alignment Health Balance (HMO C-SNP), as upgrades and non-Medicare-covered stays are not covered. Covered psychiatric admissions require no coinsurance, with a $120 daily copay for days 1 to 10 and no copay for days 11 to 90, while covered acute stays also require no coinsurance.
Outpatient Services See details
Outpatient services are covered by Alignment Health Balance (HMO C-SNP), featuring a $50 copay for outpatient hospital services and a $20 copay for outpatient substance abuse sessions, with no coinsurance. Ambulatory surgical center and outpatient blood services are also covered, with most outpatient services requiring prior authorization and a doctor referral.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Alignment Health Balance (HMO C-SNP) with a $55 copay and no coinsurance. A doctor referral and prior authorization are required to receive these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Alignment Health Balance (HMO C-SNP), as transportation to any health-related location is not covered. Covered ground and air ambulance services require prior authorization and have a $100 copay and no coinsurance, which is waived if you are admitted, while plan-approved medical transportation is covered for up to 42 one-way trips per year.
Emergency Services See details
Alignment Health Balance (HMO C-SNP) covers emergency services with a $75 copay and no coinsurance, and urgently needed services with no copay and no coinsurance. Worldwide emergency services are partially covered up to a $7,500 maximum limit, though worldwide emergency transportation is not covered.
Primary Care See details
Primary Care benefits are partially covered by Alignment Health Balance (HMO C-SNP), though podiatry, routine chiropractic care, and mental health specialty services are not covered. Covered psychiatric services require a $40 copay and no coinsurance, while opioid treatment program services require a 20% coinsurance and no copay.
Preventive Services See details
Preventive services are covered under the Alignment Health Balance (HMO C-SNP) plan, featuring no copay for Medicare-covered zero-dollar preventive services, annual physical exams, and kidney disease education. Some additional preventive benefits are only partially covered, excluding services such as health education, weight management, and therapeutic massage, while covering in-home support, memory fitness, and caregiver training.
Hearing Services See details
Alignment Health Balance (HMO C-SNP) covers one routine hearing exam and one fitting or evaluation for hearing aids every year with no deductible. While some prescription hearing aid services are covered, specific options like inner ear, outer ear, and over-the-ear types are not covered in practice, and over-the-counter hearing aids are also excluded.
Vision Services See details
Vision services are covered by Alignment Health Balance (HMO C-SNP), which includes one routine eye exam and a $200 annual combined maximum benefit for eyewear, such as glasses, contacts, and upgrades. There is no deductible for these services, allowing you to easily access annual eye care and corrective wear.
Dental Services See details
Dental services are partially covered by Alignment Health Balance (HMO C-SNP), featuring preventive care such as exams, cleanings, and x-rays with no copay or coinsurance. Covered comprehensive procedures 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
Alignment Health Balance (HMO C-SNP) covers home infusion bundled services with prior authorization, requiring no copay and no coinsurance to 20% coinsurance for chemotherapy, radiation, and other Part B drugs. Medicare Part B insulin drugs are covered under this benefit with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Alignment Health Balance (HMO C-SNP) with a 10% coinsurance and no copay. Prior authorization and a doctor referral are required to receive these covered services.
Medical Equipment See details
Alignment Health Balance (HMO C-SNP) partially covers medical equipment with no copays, featuring a 0% to 20% coinsurance for durable medical equipment and a 20% coinsurance for prosthetics, medical supplies, and diabetic therapeutic shoes. Diabetic supplies are not covered, and prior authorization is required for most medical equipment and supplies.
Diagnostic and Radiological Services See details
Alignment Health Balance (HMO C-SNP) partially covers diagnostic and radiological services, as diagnostic procedures, lab services, diagnostic radiological services, and outpatient X-ray services are not covered. Only therapeutic radiological services are covered, which require a 20% coinsurance and no copay.
Home Health Services See details
Home Health Services are covered by Alignment Health Balance (HMO C-SNP) with no copay and no coinsurance, though prior authorization and a doctor referral are required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Alignment Health Balance (HMO C-SNP) plan. All related sub-services, including cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services, are not covered.
Skilled Nursing Facility (SNF) See details
Alignment Health Balance (HMO C-SNP) partially covers Skilled Nursing Facility (SNF) services, as additional days beyond the Medicare-covered limit are not covered. For covered days, there is no copay for days 1 through 20, a $50 daily copay for days 21 through 100, and no coinsurance is required.
Other Services See details
Other Services are partially covered by Alignment Health Balance (HMO C-SNP), as acupuncture and Dual Eligible SNPs with Highly Integrated Services are not covered. Covered benefits include over-the-counter items, meal benefits, and digital health technology support with no copay or coinsurance, as well as personalized health risk screenings for a $75 copay and no coinsurance.
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