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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 Clark, Washoe. 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 $150.00. 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 $2499.00 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. After the deductible is met, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. In the initial coverage phase, you will pay a $0 copay for preferred generic drugs at standard and mail order pharmacies, a $45 copay for standard generic drugs, and a $100 copay for preferred brand drugs. Non-preferred drugs have a 25% coinsurance, and specialty tier drugs have a $5 copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you will pay nothing for covered drugs.
Additional Benefits
The Alignment Health smartHMO (HMO) plan offers a range of benefits, including coverage for inpatient and outpatient services, with varying copays depending on the service. Emergency, primary care, preventive, and home health services are covered, with some services having no copay. The plan also covers hearing and vision services, offering routine exams and eyewear, as well as dental services like oral exams and cleanings. Additional benefits include ambulance services, though transportation services are not covered. The plan also covers home infusion services, dialysis, and medical equipment with coinsurance. However, some services like acupuncture, over-the-counter items, and certain other services are not covered by the plan.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $125 copay for days 1-6, and no copay for days 7-90; Non-Medicare-covered Stay and Upgrades are not covered. For Inpatient Hospital Psychiatric, you'll 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, but Non-Medicare-covered Stay is not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $200 copay, Ambulatory Surgical Center (ASC) Services with a $50 copay, Outpatient Substance Abuse Services with a $35 copay for both individual and group sessions, and Outpatient Blood Services. All services require prior authorization and a doctor referral.
Partial Hospitalization See details
Partial Hospitalization is covered with a $55 copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Alignment Health smartHMO (HMO) plan. Ground ambulance services have a $100 copay, while air ambulance services have a $200 copay, with no coinsurance for either. 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 by the Alignment Health smartHMO (HMO) plan. Emergency Services have a $90 copay, Urgently Needed Services have a $15 copay, and Worldwide Emergency Services have a maximum plan benefit coverage of $25,000. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Alignment Health smartHMO (HMO) plan's Primary Care benefit covers Primary Care Physician Services, Chiropractic Services with a $10 copay, Occupational Therapy Services, Physician Specialist Services with a $5 copay, Mental Health Specialty Services with a $10 copay for individual and group sessions, Psychiatric Services with a $20 copay for individual and group sessions, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services with 20% coinsurance. Podiatry Services are not covered.
Preventive Services See details
Preventive Services are covered under the Alignment Health smartHMO (HMO) plan. This includes Medicare-covered preventive services, annual physical exams, and additional preventive services like Personal Emergency Response Systems (PERS), Fitness Benefit, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas (with prior authorization), Digital Rectal Exams, and EKG following Welcome Visit, with no copay or coinsurance. Health Education, In-Home Safety Assessment, 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.
Hearing Services See details
Hearing services include routine hearing exams and fitting/evaluation for hearing aids, each covered once per year. Prescription hearing aids and OTC hearing aids are not covered.
Vision Services See details
The Alignment Health smartHMO (HMO) plan covers vision services, including routine eye exams once per year, and eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, with a combined maximum of $100 every two years. Upgrades are not covered.
Dental Services See details
Dental Services includes coverage for oral exams with a $10 copay, dental x-rays with a $30 copay, prophylaxis (cleaning) with a $20 copay, and fluoride treatments with a $10 copay. Orthodontic Services, Adjunctive General Services, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered. Restorative Services, Endodontics, Periodontics, Prosthodontics (removable), Prosthodontics (fixed), and Oral and Maxillofacial Surgery may be covered as optional, supplemental benefits.
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%, and 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 with a doctor referral, and the coinsurance is 20%.
Medical Equipment See details
The Alignment Health smartHMO (HMO) plan covers durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Durable medical equipment has a 20% coinsurance, and there is no copay. Prosthetic devices and medical supplies have a 20% coinsurance, and no copay. Diabetic therapeutic shoes/inserts have 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 by the Alignment Health smartHMO (HMO) plan, but 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%, and there is no copay for these services.
Home Health Services See details
Home Health Services are covered by the Alignment Health smartHMO (HMO) plan with no copay and no coinsurance, but require authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are generally covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization and a doctor's referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Alignment Health smartHMO (HMO) plan, but require prior authorization and a doctor's referral. For days 1-20, there is a $20 copay, and for days 21-100, the copay is $100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Alignment Health smartHMO (HMO) plan's other services are not covered, including acupuncture, over-the-counter items, meal benefits, 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; however, Digital Health Technology Support is covered.
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