A non-government entity
Alignment Health Balance (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Alignment Health Balance (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Alignment Health Balance (PPO) in 2025, please refer to our full plan details page.
Alignment Health Balance (PPO) is a PPO plan offered by Alignment Healthcare USA, LLC available for enrollment in 2025 to people living in San Joaquin and Stanislaus. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Alignment Health Balance (PPO) 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 Balance (PPO).
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 Balance (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $41.00. 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 combined Maximum Out-Of-Pocket cost of $5150.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $5150.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 Balance (PPO)
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 Balance (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay for your prescriptions depending on the drug tier and pharmacy used. For example, you will pay a $3 copay for preferred generic drugs at a standard pharmacy or a $40 copay for standard generic drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Alignment Health Balance (PPO) plan offers a range of benefits, including coverage for inpatient hospital stays, outpatient services, and emergency services. For inpatient hospital stays, you'll pay a copay, and outpatient services have copays for services like ambulatory surgical centers. Emergency services have a copay, and urgently needed services have no copay or coinsurance. The plan also covers primary care, preventive services, and vision services with no copay. Hearing exams are covered with no copay, and dental services are partially covered. The plan includes additional benefits like home health services, and dialysis services, all with no copay.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered with prior authorization. For Inpatient Hospital-Acute, you pay a $75 copay for days 1-3, and no copay for days 4-90. For Inpatient Hospital Psychiatric, you pay a $120 copay 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 stays and upgrades for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a $200 copay, Ambulatory Surgical Center (ASC) Services with a $100 copay, and outpatient substance abuse services with a $20 copay for individual and group sessions. Outpatient blood services are also covered, with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered by the Alignment Health Balance (PPO) plan, with a $55 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Alignment Health Balance (PPO) plan. Ground and air ambulance services each have a $100 copay, which is waived if admitted to the hospital, while transportation services to any health-related location are covered for up to 26 one-way trips per year with medical transport. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered by the Alignment Health Balance (PPO) plan. Emergency Services have a $75 copay and no coinsurance, while Urgently Needed Services have no copay or coinsurance. Worldwide Emergency Services has a maximum plan benefit of $25,000, and Worldwide Emergency Transportation is not covered.
Primary Care See details
The Alignment Health Balance (PPO) plan covers primary care physician services, occupational therapy services, physician specialist services, psychiatric services, and other health care professional services with no copay and no coinsurance for occupational therapy services. This plan also covers physical therapy and speech-language pathology services, and additional telehealth benefits with no copay and no coinsurance. Individual and group sessions for psychiatric services have a $40 copay, and Opioid Treatment Program Services have a 20% coinsurance. Chiropractic Services, and Physical Therapy and Speech-Language Pathology Services require prior authorization. Routine Chiropractic Care, and Individual/Group Sessions for Mental Health Specialty Services are not covered.
Preventive Services See details
The Alignment Health Balance (PPO) plan covers preventive services, including annual physical exams, with no copay. Additional services such as Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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. Additional covered services include Fitness Benefit, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas (with prior authorization), Digital Rectal Exams, and EKG following Welcome Visit.
Hearing Services See details
Hearing exams, including routine hearing exams and fitting/evaluation for hearing aids, are covered with no copay, with one exam or evaluation covered per year. Prescription hearing aids and OTC hearing aids are not covered.
Vision Services See details
The Alignment Health Balance (PPO) plan covers vision services, including routine eye exams, with no copay. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, and frames, is covered up to a combined maximum of $200 per year for in-network services, with a limit of one pair of contact lenses, eyeglasses, and eyeglass lenses, and one eyeglass frame per year. Upgrades are not covered.
Dental Services See details
Dental Services are partially covered under the Alignment Health Balance (PPO) plan. While Medicare Dental Services are covered, Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered with prior authorization. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered with this plan. There is no copay or coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits are covered under the Alignment Health Balance (PPO) plan. Durable Medical Equipment (DME) has no copay, and a coinsurance between 0% and 20%, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have no copay, with a 20% coinsurance for Medicare-covered supplies. Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance, while Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Alignment Health Balance (PPO) plan. While there is no copay for any of the covered 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 Balance (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are generally covered, but specific services like Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not 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 Balance (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $50. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $20.00 every month, as well as Other 1, which requires prior authorization and has a $75 copay. Acupuncture, Meal Benefit, 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, and Self-Directed Personal Assistance Services are not covered.
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