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 2025, 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 2025.
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 has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay varying copays or coinsurance amounts depending on the drug tier and pharmacy type. For example, you will have no copay for preferred generic drugs at a standard or mail pharmacy, and a $40 copay for standard generic drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. However, you may still have to pay for excluded drugs covered under any enhanced benefit. If you qualify for the low-income subsidy (LIS), you will pay $0.00.
Additional Benefits
The Alignment Health CommUnity (HMO) plan offers a wide range of benefits. This plan covers inpatient hospital stays, outpatient services, and emergency services, all with varying copays. It also includes primary care, preventive services, and home health services with no copay. Additional benefits include coverage for hearing, vision, and dental services, with specific limits and copays. The plan also covers ambulance and transportation services, along with some medical equipment and home infusion services. Furthermore, the plan offers coverage for other services such as acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. Inpatient Hospital Psychiatric has a copay of $120 for days 1-10, and no copay for days 11-90. Additional Days for Inpatient Hospital Psychiatric are covered for up to 40 days. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient Hospital Services and Individual and Group Sessions for Outpatient Substance Abuse have a $50 copay, while Outpatient Blood Services include an enhanced benefit of three (3) pints deductible waived.
Partial Hospitalization See details
Partial Hospitalization is covered by the Alignment Health CommUnity (HMO) plan, but requires prior authorization and a doctor's referral. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services, each with a $50 copay, and transportation services to a plan-approved health-related location, with a limit of 24 one-way trips per year. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Alignment Health CommUnity (HMO) plan, with a $50 copay and no coinsurance. Worldwide Emergency Services are also covered, with a maximum plan benefit coverage of $50,000; however, Worldwide Emergency Transportation is not covered.
Primary Care See details
The Alignment Health CommUnity (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, podiatry services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Occupational therapy and physical therapy have no copay or coinsurance, while psychiatric services have a $20 copay per individual or group session, and opioid treatment program services have 20% coinsurance.
Preventive Services See details
The Alignment Health CommUnity (HMO) plan covers preventive services, including Medicare-covered services with no copay. Other covered services include annual physical exams, additional preventive services, personal emergency response systems, in-home support services, support for caregivers of enrollees, and fitness benefits. The plan does not cover health education, in-home safety assessments, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, 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 routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams and fitting/evaluation for hearing aids are covered once per year. Prescription hearing aids (all types) are covered with a copay between $195 and $1750, twice per year. Prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, nor are over-the-counter hearing aids.
Vision Services See details
Vision Services include coverage for eye exams, including routine eye exams once per year. Eyewear is covered up to a combined maximum of $300 per year, and includes contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Upgrades are not covered.
Dental Services See details
The Alignment Health CommUnity (HMO) plan covers a variety of dental services, including oral exams, dental x-rays, cleanings, fluoride treatments, restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. The plan has a service-specific out-of-pocket maximum of $1500, and does not cover adjunctive general services, maxillofacial prosthetics, implant services, or orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay, and 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 by the Alignment Health CommUnity (HMO) plan, but require prior authorization and a doctor referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 0-20% coinsurance, Prosthetic Devices with 20% coinsurance, and Medical Supplies with 20% coinsurance, but Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered. Diabetic Therapeutic Shoes/Inserts have a coinsurance between 20% and 20%.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered under the Alignment Health CommUnity (HMO) plan. While there is no copay for any of the services, 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%.
Home Health Services See details
Home Health Services are covered by the Alignment Health CommUnity (HMO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are generally covered, but none of the sub-services are covered. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Alignment Health CommUnity (HMO) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20, and a $50 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Alignment Health CommUnity (HMO) plan covers acupuncture, over-the-counter (OTC) items, and a meal benefit. The plan provides up to $25 per month for OTC items, and also includes Digital Health Technology Support. However, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and other services are not covered.
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