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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 Ventura, Stanislaus, Santa Clara, Merced. 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 $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 $615.00 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) features an Enhanced Alternative drug benefit with an annual prescription drug deductible of $615.00. After meeting this deductible, you enter the initial coverage phase where standard pharmacy and mail-order prescriptions cost a $3.00 copay for Tier 1 preferred generics, a $45.00 copay for Tier 2 standard generics, a $100.00 copay for Tier 3 preferred brands, 25% coinsurance for Tier 4 non-preferred drugs, and a $5.00 copay for Tier 5 specialty drugs. These cost-sharing rates apply until your total drug costs reach $2,100.00. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and will have no copay for Medicare Part D covered drugs. Additionally, beneficiaries who qualify for the low-income subsidy, also known as Extra Help, will benefit from no cost for their Part D coverage.
Additional Benefits
The Alignment Health smartHMO (HMO) plan offers affordable coverage for core medical needs, featuring no copay for primary care visits, urgent care, and Medicare-covered preventive services. Specialist visits require copays ranging from $5 to $20, while emergency room visits have a $120 copay with no coinsurance. For inpatient acute hospital stays, members are responsible for a $200 daily copay for the first five days, followed by no copay for days six through ninety. Supplemental benefits include routine dental services with no copay, comprehensive dental care with copays from $15 to $570, and annual routine vision and hearing exams. Members also receive a $100 eyewear allowance every two years, although hearing aids and diabetic supplies are not covered by this plan. Durable medical equipment and dialysis services are covered with a 20% coinsurance and no copay, while home health services are covered with prior authorization.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by Alignment Health smartHMO (HMO) with no coinsurance. Acute stays require a $200 daily copay for days 1 to 5 (no copay for days 6 to 90), while psychiatric stays require a $120 daily copay for days 1 to 10 (no copay for days 11 to 90); upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered under the Alignment Health smartHMO (HMO) with no coinsurance, featuring a $200 copay for outpatient hospital services, a $50 copay for ambulatory surgical center services, and a $35 copay for outpatient substance abuse sessions. Outpatient blood and observation services are also covered with no deductible or coinsurance.
Partial Hospitalization See details
Alignment Health smartHMO (HMO) covers partial hospitalization benefits with a $55.00 copay and no coinsurance. A doctor referral and prior authorization are required to receive these services.
Ambulance and Transportation Services See details
Alignment Health smartHMO (HMO) provides partial coverage for ambulance and transportation services, as transportation services to plan-approved or any health-related locations are not covered. Covered ground ambulance services require a $100 copay and no coinsurance, while air ambulance services require a $200 copay and no coinsurance, with prior authorization required for all ambulance services.
Emergency Services See details
Emergency Services are partially covered by Alignment Health smartHMO (HMO) as worldwide emergency transportation is not covered. Emergency room visits require a $120 copay and no coinsurance, urgently needed services have no copay and no coinsurance, and worldwide emergency and urgent care are covered up to a $100,000 limit with a $50 copay and no coinsurance.
Primary Care See details
Alignment Health smartHMO (HMO) provides partial coverage for primary care, as podiatry services and routine chiropractic care are not covered. Covered benefits require no copay for primary care visits, copays ranging from $5 to $20 for specialist and mental health services, and a 20% coinsurance for opioid treatment, with no coinsurance for remaining services.
Preventive Services See details
Preventive services are partially covered by Alignment Health smartHMO (HMO), featuring Medicare-covered zero-dollar preventive services with no copay and no coinsurance. While annual physical exams, glaucoma screenings, and kidney disease education are covered, several supplemental services such as health education, in-home safety assessments, and weight management programs are not covered.
Hearing Services See details
Alignment Health smartHMO (HMO) covers one routine hearing exam and one hearing aid fitting evaluation per year with no deductible. While some prescription hearing services are listed as covered, in practice, OTC hearing aids and all prescription hearing aid types—including inner ear, outer ear, and over the ear devices—are not covered.
Vision Services See details
Vision services are partially covered by Alignment Health smartHMO (HMO), which features no deductible for one routine eye exam annually and a $100 eyewear allowance every two years, though eyewear upgrades are not covered. Specific copay and coinsurance information is not provided for these services.
Dental Services See details
Dental services are partially covered under the Alignment Health smartHMO (HMO) plan, excluding adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics. Covered preventive services require no copay or coinsurance, while covered comprehensive services require copays ranging from $15.00 to $570.00 with no coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Alignment Health smartHMO (HMO), subject to prior authorization. Medicare Part B insulin drugs require a $35 copay and 0% to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and 0% to 20% coinsurance.
Dialysis Services See details
Alignment Health smartHMO (HMO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to access these covered services.
Medical Equipment See details
Alignment Health smartHMO (HMO) partially covers medical equipment, as diabetic supplies are not covered. Covered services, including durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes, require a 20% coinsurance and no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by Alignment Health smartHMO (HMO), featuring no copay and a 20% coinsurance for therapeutic radiological services. All other sub-services, including diagnostic procedures, lab services, diagnostic radiological services, and outpatient X-ray services, are not covered under this plan.
Home Health Services See details
Home health services are covered by Alignment Health smartHMO (HMO), requiring members to obtain prior authorization and a doctor referral.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered in practice under the Alignment Health smartHMO (HMO); while the plan indicates some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are all not covered.
Skilled Nursing Facility (SNF) See details
Alignment Health smartHMO (HMO) covers Skilled Nursing Facility (SNF) benefits with no coinsurance, requiring a $20 copay per day for days 1 through 20 and a $100 copay per day for days 21 through 100. Prior authorization and a doctor referral are required, and additional days beyond Medicare-covered SNF care are not covered.
Other Services See details
Other Services are partially covered by Alignment Health smartHMO (HMO), which offers coverage for Digital Health Technology Support with no maximum limit, though specific copay and coinsurance details are not provided. Acupuncture, over-the-counter (OTC) items, meal benefits, and highly integrated dual-eligible SNP services are not covered under this plan.
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