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Saint Alphonsus Health Plan Cash Back (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Saint Alphonsus Health Plan Cash Back (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Saint Alphonsus Health Plan Cash Back (HMO) in 2025, please refer to our full plan details page.
Saint Alphonsus Health Plan Cash Back (HMO) is a HMO plan offered by Trinity Health Corporation available for enrollment in 2025 to people living in Select Counties in Idaho. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Saint Alphonsus Health Plan Cash Back (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 Saint Alphonsus Health Plan Cash Back (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 Saint Alphonsus Health Plan Cash Back (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 $112.00. 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 $200.00 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 $6900.00 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 Saint Alphonsus Health Plan Cash Back (HMO) plan has a $200 deductible for prescription drugs. Once the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, in the initial coverage phase, you may pay a $10 copay for preferred generic drugs at a preferred pharmacy, or 25% coinsurance for standard generic drugs at a preferred or standard pharmacy. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Saint Alphonsus Health Plan Cash Back (HMO) plan offers a variety of benefits with varying cost-sharing. This plan includes coverage for inpatient and outpatient hospital services, with copays ranging from $0 to $395 depending on the service. Other key benefits include no copay for primary care physician services, annual physical exams, routine hearing exams, vision eyewear, and many dental services. The plan also covers ambulance services with copays, and emergency services. Diagnostic and radiological services, home health services, and skilled nursing facilities are covered, some with copays, and some with coinsurance. Additionally, the plan provides coverage for hearing, vision, and dental services, along with other services like acupuncture, over-the-counter items, and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered by Saint Alphonsus Health Plan Cash Back (HMO). For Inpatient Hospital-Acute, you have a $395 copay for days 1-5, and no copay for days 6-90. Inpatient Hospital Psychiatric has a $395 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stays and Upgrades are not covered. Additional days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a copay of $10.00 - $395.00, observation services with no copay, ambulatory surgical center services with a $395.00 copay, and outpatient substance abuse services with a copay of $40.00 for both individual and group sessions. Outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Saint Alphonsus Health Plan Cash Back (HMO) plan, with a copay of $60.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a $275 copay for ground ambulance services and a $325 copay for air ambulance services, and no coinsurance. 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. Emergency Services have a $110 copay, Urgently Needed Services have a $45 copay, Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, and Worldwide Emergency Transportation has a copay between $275 and $325.
Primary Care See details
Primary Care Physician Services have no copay. Chiropractic Services require a $15 copay, but routine care is not covered. Occupational Therapy Services have a $35 copay and no coinsurance. Physician Specialist Services have a $40 copay. Mental Health Specialty Services, including individual and group sessions, have a $40 copay. Other Health Care Professional services have a copay between $0 and $40. Psychiatric Services, including individual and group sessions, have a $40 copay. Physical Therapy and Speech-Language Pathology Services have a $35 copay and no coinsurance. Additional Telehealth Benefits have a copay between $0 and $40. Opioid Treatment Program Services have a $40 copay.
Preventive Services See details
Preventive services, including annual physical exams, are covered. Annual physical exams have no copay. Some additional preventive services, such as Fitness Benefit and Remote Access Technologies, have no copay. Other preventive services, such as Health Education, are not covered.
Hearing Services See details
Hearing Services includes hearing exams with a $40 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay; prescription hearing aids are covered with a copay between $599 and $899, while OTC hearing aids, and prescription hearing aids for the inner, outer, and over the ear are not covered. Routine hearing exams are limited to one per year, and prescription hearing aids are limited to two per year.
Vision Services See details
Vision Services include eye exams with a copay of $0-$40, and eyewear with no copay. Contact lenses, eyeglasses (lenses and frames), and eyeglass lenses are covered with no copay, and eyeglass frames are covered with no copay. Upgrades are not covered.
Dental Services See details
The Saint Alphonsus Health Plan Cash Back (HMO) plan covers Medicare Dental Services with a $40 copay, and covers other dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and fluoride treatment with no copay. This plan also covers restorative services and oral and maxillofacial surgery with 50% coinsurance, but does not cover endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, or orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered with prior authorization. Medicare Part B Insulin Drugs have a $35 copay, 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 under the Saint Alphonsus Health Plan Cash Back (HMO) plan. There is a 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered, with a 20% coinsurance for Durable Medical Equipment (DME), Medicare-covered prosthetic devices, and medical supplies. Diabetic supplies have no copay, and diabetic therapeutic shoes/inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a $50 copay for Diagnostic Procedures/Tests and a $10 copay for Lab Services. Outpatient X-Ray Services have a $40 copay, while Diagnostic Radiological Services have a copay of at least $275, and Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered under the Saint Alphonsus Health Plan Cash Back (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. The plan has a copay for some Cardiac and Pulmonary Rehabilitation Services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, with no copay for days 1-20 and days 56-100, and a $214 copay for days 21-55. Additional days beyond Medicare-covered for SNF, and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Saint Alphonsus Health Plan Cash Back (HMO) plan covers acupuncture with a $20 copay, up to 6 treatments per year, and over-the-counter (OTC) items with no copay, up to $50 every three months. The plan also offers a meal benefit with no copay. However, 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.
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