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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 2025, 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 2025.
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 $590.00 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 "Enhanced Alternative" drug benefit. The plan has a deductible of $590. Once you meet your deductible, you will pay a copay or coinsurance for your prescriptions. For preferred generic drugs, you pay a $3 copay at standard and mail order pharmacies. Standard generic drugs have a $45 copay, and preferred brand drugs have a $100 copay. Non-preferred drugs have a 25% coinsurance, and specialty tier drugs have a $5 copay. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for covered drugs.
Additional Benefits
The Alignment Health smartHMO (HMO) plan offers a range of benefits, including coverage for inpatient hospital stays with a copay, outpatient services, and ambulance services. The plan also covers primary care, preventive services, and hearing and vision services, as well as dental services. This plan provides coverage for services like home health, skilled nursing facilities, and dialysis services. The plan also covers medical equipment, diagnostic and radiological services, and home infusion bundled services. There are also a wide range of other services that are covered, and some that are not.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for both acute and psychiatric care, with prior authorization and a doctor's referral required. For Inpatient Hospital-Acute, you'll pay a $275 copay for days 1-6, and no copay for days 7-90; Inpatient Hospital Psychiatric has a $120 copay for days 1-10, and no copay for days 11-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a $200 copay, Ambulatory Surgical Center (ASC) Services with a $50 copay, and Outpatient Substance Abuse Services, including individual and group sessions with a copay between $35 and $35. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the plan, but requires prior authorization and a doctor referral. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Alignment Health smartHMO (HMO). Both ground and air ambulance services have a $200 copay, and there is no coinsurance; however, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Alignment Health smartHMO (HMO) plan. Emergency Services have a $120 copay, Urgently Needed Services have a $15 copay, and Worldwide Emergency Services has a maximum plan benefit coverage of $25,000; all services have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Alignment Health smartHMO (HMO) plan covers Primary Care Physician, Occupational Therapy, Physician Specialist, Mental Health Specialty, Psychiatric, Physical Therapy and Speech-Language Pathology, Additional Telehealth, and Opioid Treatment Program services. Physician Specialist services have a $15 copay, Individual and Group sessions for Mental Health Specialty services have a $10 copay, and Individual and Group sessions for Psychiatric services have a $20 copay. Chiropractic services and Opioid Treatment Program Services require prior authorization and a doctor referral. Routine Chiropractic Care is not covered, and Opioid Treatment Program Services have a 20% coinsurance.
Preventive Services See details
Preventive Services, including Medicare-covered services and annual physical exams, are covered by the Alignment Health smartHMO (HMO) plan. Additional preventive services are partially covered, but health education, in-home safety assessments, medical nutrition therapy, 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 benefits, 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, home and bathroom safety devices, and counseling services are not covered. The plan also covers kidney disease education services, glaucoma screenings, diabetes self-management training, digital rectal exams, and EKGs following a welcome visit. Personal Emergency Response System (PERS) and fitness benefits are offered as optional supplemental benefits, and Barium Enemas are covered with prior authorization.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids, with one visit covered per year. Prescription and OTC hearing aids are not covered.
Vision Services See details
The Alignment Health smartHMO (HMO) plan covers vision services, including routine eye exams with one visit every year and eyewear with a combined maximum benefit of $100 every two years, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Upgrades are not covered.
Dental Services See details
The Alignment Health smartHMO (HMO) plan covers oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments, but requires prior authorization and a doctor referral. Orthodontic, restorative, and other dental services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs also have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Alignment Health smartHMO (HMO) plan with a doctor referral required. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and no copay, Prosthetics/Medical Supplies with a 20% coinsurance and no copay, and Diabetic Therapeutic Shoes/Inserts with a 20% coinsurance and no copay. Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Alignment Health smartHMO (HMO) plan, with no copay for any services. Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, and Outpatient X-Ray Services are not covered, while Therapeutic Radiological Services have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Alignment Health smartHMO (HMO) plan, with no copay and no coinsurance, but this benefit requires prior authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. A referral and prior authorization from your doctor are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Alignment Health smartHMO (HMO) plan, with prior authorization and a doctor's referral required. For days 1-20, there is a $20 copay, and for days 21-100, there is a $100 copay. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services, including acupuncture, over-the-counter items, and meal benefits, are not covered by the Alignment Health smartHMO (HMO) plan. Some other services are covered, including digital health technology support.
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