A non-government entity
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 Sacramento, Placer, Yolo. 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 $140.00. 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 a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3499.00 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 Alignment Health smartHMO (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Alignment Health smartHMO (HMO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590. Once you meet your deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For those with low incomes, this plan may have a reduced premium, and those who qualify for full low-income subsidy (LIS) will have no copay for Part D drugs. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Alignment Health smartHMO (HMO) plan offers a range of benefits with varying costs. This plan covers inpatient hospital stays with copays, outpatient services with copays, and emergency services with a $120 copay. The plan also includes coverage for primary care, hearing, vision, and dental services, with specific copays and limitations depending on the service. Additional benefits include home health services, skilled nursing facility stays, and medical equipment.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $200 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you will pay a $120 copay for days 1-10, and no copay for days 11-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a $200 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, with the plan waiving the three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires 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 smartHMO (HMO) plan. Ground ambulance services have a $100 copay, and air ambulance services have a $200 copay, with no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Alignment Health smartHMO (HMO) plan. Emergency Services have a $120 copay, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $50 copay; all other services have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Alignment Health smartHMO (HMO) plan covers 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. The 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, additional telehealth benefits, and opioid treatment program services with 20% coinsurance. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Alignment Health smartHMO (HMO) plan covers preventive services, including Medicare-covered services, annual physical exams, and additional preventive services. Additional preventive services include Fitness Benefit, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas (with prior authorization), Digital Rectal Exams, and EKG following Welcome Visit. However, Health Education, In-Home Safety Assessment, Medical Nutrition Therapy, 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 (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. Personal Emergency Response System (PERS) is covered as an optional supplemental benefit; contact the plan for details.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids, each covered once per year; however, prescription hearing aids and OTC hearing aids are not covered. There is no copay, deductible, or coinsurance for hearing exams.
Vision Services See details
Vision services include routine eye exams, eyewear, and contact lenses. Routine eye exams are covered annually, while eyewear (lenses and frames) and contact lenses are covered every two years, with a combined maximum benefit of $100 for eyewear.
Dental Services See details
The Alignment Health smartHMO (HMO) plan covers a range of dental services, including oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments. Restorative services have a copay of $20-$400, endodontics have a copay of $25-$350, periodontics have a copay of $15-$550, prosthodontics (removable) have a copay of $20-$570, prosthodontics (fixed) have a copay of $40-$400, and oral and maxillofacial surgery have 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 are covered, and prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay with 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, but require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits under the Alignment Health smartHMO (HMO) plan include Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance. Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Alignment Health smartHMO (HMO) plan, but Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, and Outpatient X-Ray Services are not covered. Therapeutic Radiological Services have a coinsurance of at most 20%, and there is no copay for these services.
Home Health Services See details
Home Health Services are covered by the Alignment Health smartHMO (HMO) plan with no copay and no coinsurance, but require authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but not in practice. Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Alignment Health smartHMO (HMO) plan, but require prior authorization and a doctor referral. For days 1-20, there is a $20 copay, and for days 21-100, there is a $100 copay. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Alignment Health smartHMO (HMO) plan does not cover 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, or Self-Directed Personal Assistance Services. Other Services and Other 2 benefits are covered, including Digital Health Technology Support.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved