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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 Ventura, Stanislaus, Santa Clara, Merced. 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 $115.00. 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 $3999.00 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 an enhanced alternative drug benefit. The plan has a deductible of $590. After the deductible is met, you'll pay a copay for your prescriptions depending on the drug tier and whether you use a preferred or standard pharmacy. For preferred generic drugs, there is no copay. For standard generic drugs, the copay is $3.00. Preferred brand drugs have a $100 copay. Non-preferred drugs have 25% coinsurance, and specialty tier drugs have a $5.00 copay. After your total drug costs reach $2000, you pay nothing for covered drugs.
Additional Benefits
The Alignment Health smartHMO (HMO) plan offers comprehensive coverage with varying costs for different services. Inpatient hospital stays have a copay, while outpatient services and emergency services have their own copays. The plan also includes benefits like vision, dental, and hearing services, each with specific limitations and cost-sharing. Other covered services include home health, skilled nursing, and home infusion, but may require prior authorization or have coinsurance.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. 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 outpatient hospital services with a $200 copay, ambulatory surgical center services with a $50 copay, and outpatient substance abuse services with a $35 copay for individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Alignment Health smartHMO (HMO) plan, 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, but require prior authorization. Ground Ambulance Services have a $100 copay, and Air Ambulance Services have a $200 copay. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Coverage, are covered by the Alignment Health smartHMO (HMO) plan. Emergency Services have a $120 copay and no coinsurance, Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $50 copay and no coinsurance, and 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 Physical Therapy and Speech-Language Pathology Services with no copay or coinsurance, and Opioid Treatment Program Services with 20% coinsurance. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive services are covered, including Medicare-covered services, annual physical exams, and other preventive services. Additional preventive services are partially covered, with the following services not covered: 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, Home and Bathroom Safety Devices and Modifications, and Counseling Services.
Hearing Services See details
Hearing services include coverage for routine hearing exams and fitting/evaluation for hearing aids, each limited to one visit per year, with no copay or coinsurance. Prescription hearing aids and over-the-counter hearing aids are not covered.
Vision Services See details
The Alignment Health smartHMO (HMO) plan covers vision services, including routine eye exams with 1 visit allowed every year, and eyewear including contact lenses, eyeglass lenses, and eyeglass frames with a combined maximum of $100 every two years. Upgrades are not covered.
Dental Services See details
The Alignment Health smartHMO (HMO) plan covers a variety of dental services, including oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatment, with copays ranging from $20 to $400 for restorative services, $25 to $350 for endodontics, $15 to $550 for periodontics, $20 to $570 for removable prosthodontics, $40 to $400 for fixed prosthodontics, and $25 to $250 for oral and maxillofacial surgery. Adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
The Alignment Health smartHMO (HMO) plan covers Durable Medical Equipment (DME) with a 20% coinsurance and no copay, as well as Prosthetic Devices and Medical Supplies with a 20% coinsurance and no copay. Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance and no copay. 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, with no copay for some services. Some services, including Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, and Outpatient X-Ray Services, are not covered; Therapeutic Radiological Services are covered with a coinsurance of at most 20%.
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 both 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 none of the sub-services, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered, but require prior authorization and a doctor's referral. For days 1-20, there is a $20 copay, and for days 21-100, there is a $100 copay. Additional days beyond Medicare coverage and non-Medicare covered stays are not covered.
Other Services See details
The Alignment Health smartHMO (HMO) plan does not cover acupuncture, over-the-counter items, or meal benefits. Other services, including digital health technology support, are covered. The plan also does not cover 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.
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