Alignment Health CalPlus + Veterans (HMO)
Alignment Health CalPlus + Veterans (HMO) H3815-036 Plan Details
Alignment Health CalPlus + Veterans (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Alignment Health Plan.
Plan ID: H3815-036.
$0.00
Monthly Premium
Alignment Health CalPlus + Veterans (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Alignment Health Plan.
Plan ID: H3815-036.
California Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5900 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit Prior authorization required |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $0.00 per day for days 1 to 60 $389.00 per day for days 61 to 90 Deductible $1556.00 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services These rates may change for 2023 Prior authorization required |
| Urgent Care | Coinsurance for Urgent Care 20% Worldwide Coverage: Copayment for Worldwide Emergency/Urgent Coverage $75.00 Maximum Plan Benefit of $10,000 |
| Emergency Room Visit | Coinsurance for Emergency Care 20% Coinsurance for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days Worldwide Coverage: Copayment for Worldwide Emergency/Urgent Coverage $75.00 Maximum Plan Benefit of $10,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Coinsurance for Ground Ambulance Services 20% Not waived if admitted Air Ambulance: Coinsurance for Air Ambulance Services 20% Not waived if admitted Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
Alignment Health CalPlus + Veterans (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $0.00 Copayment for Routine Care $0.00 (available through FLEX Allowance) Prior Authorization Required for Chiropractic Services Referral Required for Chiropractic Services Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Referral Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Referral Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $0.00 per day for days 1 to 60 $389.00 per day for days 61 to 90 Deductible $1556.00 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services These rates may change for 2023 Prior authorization required |
| Mental Health Outpatient Care | In-Network: Coinsurance for Medicare-covered Individual Sessions 20% Coinsurance for Medicare-covered Group Sessions 20% Prior Authorization Required for Outpatient Mental Health Services Referral Required for Outpatient Mental Health Services Prior authorization required |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Prior Authorization Required for Outpatient Observation Services Referral Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Coinsurance for Medicare-covered Individual Sessions 20% Coinsurance for Medicare-covered Group Sessions 20% Prior Authorization Required for Outpatient Substance Abuse Services Referral Required for Outpatient Substance Abuse Services Prior authorization required |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $10.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0.00 Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services Prior authorization required |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $185.50 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services These rates may change for 2023 Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Maximum Plan Allowance of $150.00 every three months for Preventive and Non-Medicare Covered Comprehensive combined through FLEX Allowance Prior Authorization Required for Preventive Dental Referral Required for Preventive Dental Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Copayment for Diagnostic Services $0.00 Copayment for Restorative Services $0.00 Copayment for Endodontics $0.00 Copayment for Periodontics $0.00 Copayment for Extractions $0.00 Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00 Maximum Plan Benefit of $150.00 every three months for Preventive and Non-Medicare Covered Comprehensive combined through FLEX Allowance Prior Authorization Required for Comprehensive Dental Referral Required for Comprehensive Dental Prior authorization required |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00 Copayment for Eyeglasses (lenses and frames) $0.00 Copayment for Eyeglass Lenses $0.00 Copayment for Eyeglass Frames $0.00 Prior Authorization Required for Eyewear Members will receive a FLEX Allowance through their combined benefit. The allowance provided may be used towards the purchase of vision services. Prior authorization required |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Hearing Exams $0.00
Referral Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $0.00 Prior Authorization Required for Hearing Aids Referral Required for Hearing Aids Members will receive a FLEX Allowance through their combined benefit. The allowance provided may be used towards the purchase of hearing services. Prior authorization required |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The Alignment Health CalPlus + Veterans (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $0 (excludes Tiers 1 and 6) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $0 (excludes Tiers 1 and 6) |
| Preferred Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $0 (excludes Tiers 1 and 6) |
| Preferred Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $0 (excludes Tiers 1 and 6) |
| Preferred Generic |
|
| Select Care Drugs |
|
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