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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 Mountains and Piedmont Regions. This plan received an overall rating of 5 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 $142.00. 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 $3400.00 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 annual prescription drug deductible of $615. For Tier 1 preferred generic drugs, members pay no copay for up to a three-month supply at standard pharmacies and through standard mail order. Tier 2 generic drugs are also highly affordable, starting at a $3 copay for a one-month supply. Tier 3 preferred brand drugs carry a $45 copay for a one-month supply, while Tier 6 select care drugs have a $5 copay that drops to no copay for a three-month supply. For higher-tier medications, members pay coinsurance rather than a flat copay, which includes 40% coinsurance for Tier 4 non-preferred drugs and 25% coinsurance for Tier 5 specialty drugs.
Additional Benefits
The Alignment Health smartHMO (HMO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits, telehealth, physical therapy, and home health services. Specialist visits require a $30 copay, and inpatient hospital stays require a daily copay of $275 for the first six days. Emergency room visits have a $120 copay, which is waived if you are admitted, while urgently needed services require a $15 copay. Routine dental, vision, and hearing exams are fully covered with no copay, and the plan provides a $100 allowance for eyewear every two years. For durable medical equipment, dialysis, and therapeutic radiological services, you will pay no copay and a 20% coinsurance. It is important to note that this plan does not cover hearing aids, diabetic supplies, or cardiac rehabilitation.
Inpatient Hospital See details
Alignment Health smartHMO (HMO) partially covers inpatient hospital services with no coinsurance, though prior authorization and referrals are required. Acute stays require a $275 daily copay for days 1 through 6 with no copay for days 7 through 90, and psychiatric stays require a $120 daily copay for days 1 through 10 with no copay for days 11 through 90, while upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Alignment Health smartHMO (HMO) covers outpatient services 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 services are covered with no copay and no coinsurance, though prior authorization and referrals are required for most services.
Partial Hospitalization See details
Alignment Health smartHMO (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization and a referral are required to access this benefit.
Ambulance and Transportation Services See details
Alignment Health smartHMO (HMO) covers ground and air ambulance services with a $200 copay and no coinsurance, with the copay waived if you are admitted to the hospital. Ambulance services require prior authorization, while plan-approved and other health-related transportation services are not covered.
Emergency Services See details
Alignment Health smartHMO (HMO) covers emergency services with a $120 copay and no coinsurance, which is waived if admitted to the hospital within 48 hours, and urgently needed services with a $15 copay and no coinsurance. Worldwide emergency and urgent services are partially covered up to a $25,000 maximum with no copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Alignment Health smartHMO (HMO) provides primary care, telehealth, occupational therapy, physical therapy, and speech-language pathology with no copay and no coinsurance. Specialist visits and other healthcare professional services require a $30 copay and no coinsurance, mental health sessions cost a $10 copay and no coinsurance, and psychiatric services have a $20 copay and no coinsurance. Opioid treatment has no copay and 20% coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Alignment Health smartHMO (HMO) preventive services are partially covered with no copay and no coinsurance for covered benefits like annual exams, kidney disease education, and glaucoma screenings. However, sub-services such as health education, in-home safety assessments, medical nutrition therapy, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, telemonitoring, and home safety modifications are not covered.
Hearing Services See details
Alignment Health smartHMO (HMO) covers hearing exams with no copay and no coinsurance, including one routine exam and one fitting evaluation every year. Hearing aids, including prescription and over-the-counter (OTC) models, are not covered by this plan.
Vision Services See details
Vision services are partially covered by Alignment Health smartHMO (HMO), featuring one routine eye exam annually and up to $100 for eyewear every two years with no copay, no coinsurance, and no deductible. Under this plan, other eye exam services and eyewear upgrades are not covered.
Dental Services See details
Dental services are partially covered by Alignment Health smartHMO (HMO) with no copay and no coinsurance for covered care, including oral exams, cleanings, fluoride, x-rays, and Medicare-covered dental. Sub-services that are not covered include restorative, endodontics, periodontics, prosthodontics, implants, oral surgery, orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive dental services.
Home Infusion bundled Services See details
Alignment Health smartHMO (HMO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B chemotherapy, radiation, and other Part B drugs require no copay and 0% to 20% coinsurance, while insulin is covered with a $35 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 referral are required for this benefit.
Medical Equipment See details
Alignment Health smartHMO (HMO) partially covers medical equipment, offering durable medical equipment, medical supplies, prosthetics, and diabetic therapeutic shoes or inserts with no copay and a 20% coinsurance. Prior authorization is required for these services, and diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by Alignment Health smartHMO (HMO), requiring prior authorization and a referral. Covered diagnostic services feature no copay and no coinsurance, but diagnostic procedures, tests, and lab services are not covered. Covered therapeutic radiological services have a 20% coinsurance and no copay, while diagnostic radiological services and outpatient X-ray services are not covered.
Home Health Services See details
Alignment Health smartHMO (HMO) covers Home Health Services with no copay and no coinsurance, although prior authorization and a referral are required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Alignment Health smartHMO (HMO), as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Alignment Health smartHMO (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $20 daily copay for days 1 to 20 and a $100 daily copay for days 21 to 100. Prior authorization and referrals are required, though a prior three-day hospital stay is not, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Alignment Health smartHMO (HMO) partially covers other services, offering digital health technology support with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered under this plan.
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