A non-government entity
Alignment Health CommUnity (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Alignment Health CommUnity (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Alignment Health CommUnity (HMO) in 2026, please refer to our full plan details page.
Alignment Health CommUnity (HMO) is a HMO plan offered by Alignment Healthcare USA, LLC available for enrollment in 2025 to people living in Fresno, Madera. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Alignment Health CommUnity (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 CommUnity (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 CommUnity (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.
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 $999.00 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 CommUnity (HMO) plan offers an enhanced alternative drug benefit with no prescription drug deductible. Under this plan, you will enjoy no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail. Tier 2 standard generic drugs are available for a $40 copay during the initial coverage phase. For higher-tier medications, Tier 3 preferred brand drugs carry a $100 copay, while Tier 5 specialty drugs cost a $5 copay. Tier 4 non-preferred drugs require a 33% coinsurance for both standard pharmacy and standard mail orders. After your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for covered Part D prescriptions.
Additional Benefits
Alignment Health CommUnity (HMO) provides comprehensive coverage with affordable cost-sharing for your core medical needs. Emergency care and ambulance transport require a $50 copay, which is waived upon hospital admission, while urgent care and preventive services are covered with no copays. Inpatient psychiatric stays feature a $120 daily copay for the first ten days and no copay for days 11 through 90, helping you manage healthcare costs. For specialized care, this plan offers a $300 annual eyewear allowance, up to $1,500 in yearly dental coverage, and routine hearing exams with no deductible. Skilled nursing facility stays require no copay for the first 20 days, while covered Medicare Part B chemotherapy and radiation services require no copay with coinsurance up to 20%. These benefits make it easier to access essential daily health services while keeping out-of-pocket costs predictable.
Inpatient Hospital See details
Inpatient Hospital benefits are partially covered by Alignment Health CommUnity (HMO) because upgrades and non-Medicare-covered stays are not covered. Covered psychiatric care requires a $120 copay per day for days 1 to 10, no copay for days 11 to 90, and no coinsurance.
Outpatient Services See details
Alignment Health CommUnity (HMO) covers outpatient services, with outpatient hospital care and outpatient substance abuse sessions requiring a $50 copay and no coinsurance. Outpatient blood services are also covered with no deductible, copay, or coinsurance, though most outpatient services require prior authorization and a doctor referral.
Partial Hospitalization See details
Alignment Health CommUnity (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization and a doctor referral are required to receive these covered benefits.
Ambulance and Transportation Services See details
Alignment Health CommUnity (HMO) covers ground and air ambulance services with a $50 copay and no coinsurance, with the copay waived if you are admitted to the hospital. Transportation benefits are partially covered, providing up to 24 one-way medical transport trips per year to plan-approved locations, while transportation to any health-related location is not covered.
Emergency Services See details
Alignment Health CommUnity (HMO) covers emergency services with a $50 copay and no coinsurance, which is waived if admitted to the hospital within 48 hours, and urgently needed services with no copay or coinsurance. Worldwide emergency and urgent care are partially covered up to a $50,000 maximum limit, but worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits are offered by Alignment Health CommUnity (HMO), including chiropractic, physical therapy, and specialist services. Psychiatric services require a $20 copay, opioid treatment has a 20% coinsurance, and while some mental health specialty services are covered, individual and group sessions are not.
Preventive Services See details
Alignment Health CommUnity (HMO) partially covers Preventive Services, providing Medicare-covered zero-dollar services, annual physicals, and kidney disease education with no copay and no coinsurance. Covered benefits also include personal emergency response systems, caregiver support, and memory fitness, though some require prior authorization. However, sub-services such as health education, in-home safety assessments, medical nutrition therapy, weight management, alternative therapies, therapeutic massage, adult day health, and home safety modifications are not covered.
Hearing Services See details
Alignment Health CommUnity (HMO) hearing services are partially covered, offering one routine hearing exam and one fitting evaluation per year with no deductible. While up to two prescription hearing aids (all types) are covered annually with a copay ranging from $195 to $1,750 and no coinsurance, OTC hearing aids as well as inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
Vision Services are partially covered by Alignment Health CommUnity (HMO), featuring no deductible for one annual routine eye exam and a $300 yearly eyewear allowance, though upgrades are not covered. No copay or coinsurance information is specified for these benefits.
Dental Services See details
Alignment Health CommUnity (HMO) partially covers dental services up to a maximum of $1,500 annually, though specific copay and coinsurance costs are not provided. Many preventive and comprehensive services are covered with prior authorization, but adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Alignment Health CommUnity (HMO) covers Home Infusion bundled Services, which require prior authorization and may involve step therapy. Medicare Part B insulin drugs require a $35 copay and range from no coinsurance up to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs require no copay and range from no coinsurance up to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Alignment Health CommUnity (HMO) with a 20% coinsurance and no copay. Prior authorization and a doctor referral are required to receive these covered services.
Medical Equipment See details
Alignment Health CommUnity (HMO) partially covers medical equipment with no copays and coinsurance ranging from no coinsurance to 20%. Covered services include durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes, but diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Alignment Health CommUnity (HMO) partially covers Diagnostic and Radiological Services, requiring prior authorization and a doctor referral. Therapeutic radiological services are covered with no copay and a 20% coinsurance, while diagnostic procedures, lab services, diagnostic radiological services, and outpatient x-rays are not covered.
Home Health Services See details
Home Health Services are covered by Alignment Health CommUnity (HMO), requiring prior authorization and a doctor referral. Details regarding specific copay and coinsurance amounts are not specified in this plan's benefit summary.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Alignment Health CommUnity (HMO) plan, as all sub-services, including intensive cardiac, pulmonary, and SET for PAD rehabilitation, are excluded from coverage.
Skilled Nursing Facility (SNF) See details
Alignment Health CommUnity (HMO) partially covers Skilled Nursing Facility (SNF) services, which require prior authorization and a doctor referral, though additional days beyond the Medicare-covered limit are not covered. For covered stays, there is no copay and no coinsurance for days 1 through 20, and a $50 daily copay with no coinsurance for days 21 through 100.
Other Services See details
Alignment Health CommUnity (HMO) covers acupuncture, digital health technology support, and home meal benefits, though specific copay and coinsurance costs are not detailed. The plan also provides a $25 monthly reimbursement for over-the-counter items, though it does not cover all CMS-listed OTC drugs, and highly integrated dual-eligible SNP services are not covered.
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