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Aspire Health Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aspire Health Advantage (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aspire Health Advantage (HMO) in 2026, please refer to our full plan details page.
Aspire Health Advantage (HMO) is a HMO plan offered by Montage Health available for enrollment in 2025 to people living in Monterey County. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Aspire Health Advantage (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 Aspire Health Advantage (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 Aspire Health Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $196.00. 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 Maximum Out-Of-Pocket cost of $4300.00 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 Aspire Health Advantage (HMO) plan offers an Enhanced Alternative prescription drug benefit featuring no drug deductible. Individuals qualifying for the low-income subsidy pay a reduced Part D premium of $32.80, compared to the standard premium of $44.80. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs. During the initial coverage phase at a standard pharmacy, Tier 1 preferred generics require a $15.00 copay, while Tier 2 standard generics cost a $47.00 copay. Higher tiers require a coinsurance of 25% for Tier 3 preferred brands and 33% for Tier 4 non-preferred drugs, while Tier 5 specialty tier drugs have an $11.00 copay.
Additional Benefits
The Aspire Health Advantage (HMO) plan offers comprehensive coverage for essential medical services, often requiring no coinsurance but utilizing fixed copayments. Inpatient hospital stays require daily copays for the first few days before transitioning to no copay, while emergency room visits carry a $115 copay and urgently needed care features no copay. Primary care, specialist visits, and routine dental, vision, and hearing exams are available with low copays ranging from no copay up to $25 and no coinsurance. For specialized care, outpatient diagnostic services and x-rays incur copays between $10 and $150, while durable medical equipment and dialysis services generally require a 20% coinsurance with no copay. Skilled nursing facility stays are covered with no copay for the first 20 days, followed by a $100 daily copay. However, this plan does not cover certain benefits such as routine eyewear, hearing aids, cardiac rehabilitation, or over-the-counter items.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Aspire Health Advantage (HMO) with no coinsurance, requiring prior authorization for both acute and psychiatric stays. Acute stays require a $600 daily copay for days 1-2, a $300 daily copay for days 3-4, and no copay for days 5-90, while psychiatric stays require a $275 daily copay for days 1-6 and no copay for days 7-90; however, additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Aspire Health Advantage (HMO) covers outpatient hospital services with a $60 to $275 copay and 20% coinsurance, and ambulatory surgical center visits for a $60 copay with no coinsurance. Observation services require a $275 daily copay, while outpatient substance abuse sessions have a $15 copay and no coinsurance. Outpatient blood services are covered with a 20% coinsurance and no copay or deductible.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Aspire Health Advantage (HMO) with a $30.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under Aspire Health Advantage (HMO), though transportation is only partially covered because transportation to any health-related location is not covered. Ground ambulance services require a $325 copay and no coinsurance, while air ambulance services require 20% coinsurance and no copay.
Emergency Services See details
Aspire Health Advantage (HMO) covers emergency services with a $115 copay, which is waived if admitted to the hospital within 24 hours, and no coinsurance, while urgently needed services have no copay and no coinsurance. Worldwide emergency services, including worldwide emergency coverage, worldwide urgent coverage, and worldwide emergency transportation, are not covered.
Primary Care See details
Primary Care benefits are partially covered under Aspire Health Advantage (HMO), as podiatry services are not covered. Covered services, including specialist visits, therapy, and chiropractic care, require copays ranging from no copay up to $25 and no coinsurance.
Preventive Services See details
Aspire Health Advantage (HMO) partially covers preventive services, providing Medicare-covered zero-dollar services, health education, and glaucoma screenings with no copay or coinsurance. However, several benefits are not covered under this plan, including annual physical exams, weight management programs, and in-home safety assessments.
Hearing Services See details
Aspire Health Advantage (HMO) partially covers hearing services, featuring routine hearing exams with a $25 copay and no coinsurance. However, fitting and evaluation for hearing aids, prescription hearing aids, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Aspire Health Advantage (HMO), which offers routine eye exams with a $25 copay, no coinsurance, and no deductible as an optional supplemental benefit. Eyewear is not covered by this plan, meaning contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by Aspire Health Advantage (HMO), which offers Medicare-covered dental services for a $25 copay and no coinsurance, as well as routine exams, cleanings, and x-rays. However, fluoride treatment, restorative services, endodontics, periodontics, prosthodontics, implant services, oral surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aspire Health Advantage (HMO) with prior authorization, offering no copay and ranging from no coinsurance to 20% coinsurance for chemotherapy, radiation, and other Part B drugs. Medicare Part B insulin drugs are also covered under this benefit with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered by Aspire Health Advantage (HMO) with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
Medical Equipment is partially covered by Aspire Health Advantage (HMO) with no copays for covered items, though diabetic therapeutic shoes and inserts are not covered. Covered durable medical equipment, prosthetic devices, and medical supplies require a 20% coinsurance, while diabetic supplies carry between no coinsurance and 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aspire Health Advantage (HMO), with prior authorization required for these benefits. Lab services, diagnostic tests, and outpatient X-rays require a $10 copay, while diagnostic radiological services have a $60 to $150 copay and therapeutic radiological services incur a 20% coinsurance.
Home Health Services See details
Home health services are covered by Aspire Health Advantage (HMO) with prior authorization required, though specific copay and coinsurance information is not detailed in the plan benefits.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Aspire Health Advantage (HMO) plan, as all individual sub-services, including intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy, are excluded from coverage.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Aspire Health Advantage (HMO), requiring prior authorization but featuring no coinsurance. Under this plan, you will pay no copay for days 1 through 20 and a $100 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by Aspire Health Advantage (HMO), which offers acupuncture benefits with a $10 copay and no coinsurance for up to 6 treatments per year. Over-the-counter (OTC) items, meal benefits, and Dual Eligible SNPs with Highly Integrated Services are not covered.
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