2027 Medicare Advantage plan

Alignment Health Heart & Diabetes Plus 004 (HMO-POS C-SNP): 2027 benefits and costs

Alignment Health Plan HMO-POS C-SNP Special Needs Plan

CMS plan ID: H5472-004-0 · Plan year: 2027

Alignment Health Heart & Diabetes Plus 004 (HMO-POS C-SNP) is a 2027 Medicare Advantage plan offered by Alignment Health Plan. It is listed in Texas.

2027 plan costs at a glance

Monthly plan premium$6.30

Drug deductible$700.00

In-network medical out-of-pocket maximum$9,850.00

Organization: Alignment Health Plan
Plan organization: ALIGNMENT HEALTH INSURANCE COMPANY OF ARIZONA INC
Parent company: Alignment Healthcare USA, LLC
Plan type: HMO-POS C-SNP
Part C premium: $0.00
Part D premium: $6.30
Prescription drug coverage: Yes
Special Needs Plan type: Chronic or Disabling Condition
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)

You must continue to pay your Medicare Part B premium.

In-network medical deductible: None
Combined in/out-of-network medical deductible: None
Out-of-network medical deductible: None
In-network medical maximum: $9,850.00
Combined in/out-of-network medical maximum: Not applicable
Out-of-network medical maximum: Not applicable

Who can join this Special Needs Plan?

This plan is for people with qualifying chronic or disabling conditions. The plan must confirm that your condition meets its eligibility rules.

Plan eligibility type: Chronic or Disabling Condition
Qualifying conditions: Diabetes Mellitus, Chronic Heart Failure, and Cardiovascular Disorders

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	Point-of-service	What to know
Primary care doctor	$0 Service-specific deductible No	Not summarized. Check coverage with the plan.
Specialist visit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required Yes
Telehealth	$0.00 to $20.00 copay Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required No Referral required No
Emergency care	20% coinsurance	Not summarized. Check coverage with the plan.
Urgent care	$0	Not summarized. Check coverage with the plan.
Home health	$0 Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required Yes Referral required Yes
Dialysis	20% coinsurance Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required Yes Referral required Yes
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	Not summarized. Check coverage with the plan.	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	Not summarized. Check coverage with the plan.	Approval required Yes
Kidney disease education services	$0 Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required No Referral required No
Medicare-covered chiropractic	$0 Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required Yes Referral required Yes
Medicare-covered foot care	$0 Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required Yes Referral required Yes
Other health professionals	20% coinsurance Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required Yes Referral required Yes

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required Yes Benefit period Original Medicare
Inpatient hospital stay	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required Yes Benefit period Original Medicare
Inpatient mental health care	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required Yes Benefit period Original Medicare
Inpatient mental health care	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required Yes Benefit period Original Medicare
Skilled nursing facility	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required Yes Benefit period Original Medicare
Skilled nursing facility	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required Yes Benefit period Original Medicare

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	What to know
Outpatient hospital care	20% coinsurance Service-specific deductible No
Hospital observation services	20% coinsurance Service-specific deductible No
Ambulatory surgical center	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Outpatient blood	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	What to know
Diagnostic procedures and tests	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Laboratory services	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Diagnostic radiology (CT, MRI)	$0 Service-specific deductible No	Approval required Yes Referral required Yes
Therapeutic radiology	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
X-rays	$0 Service-specific deductible No	Approval required Yes Referral required Yes

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	What to know
Partial hospitalization	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Intensive outpatient program	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Substance use treatment, individual sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Substance use treatment, group sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Opioid treatment program	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Mental health, individual sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Mental health, group sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Psychiatry, individual sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Psychiatry, group sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	What to know
Occupational therapy	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Physical and speech therapy	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Cardiac rehabilitation	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Intensive cardiac rehabilitation	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Pulmonary rehabilitation	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes
Supervised exercise for peripheral artery disease	20% coinsurance Service-specific deductible No	Approval required Yes Referral required Yes

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	What to know
Ground ambulance	20% coinsurance Service-specific deductible No	Approval required Yes
Air ambulance	20% coinsurance Service-specific deductible No	Approval required Yes
Durable medical equipment	20% coinsurance Service-specific deductible No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic supplies	$0 Service-specific deductible No	Approval required Yes
Diabetic shoes and inserts	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic monitors	20% coinsurance Service-specific deductible No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	What to know
Medicare-covered dental	$0
Oral examsAdditional plan benefit	$0
Dental X-raysAdditional plan benefit	$0
Dental cleaningAdditional plan benefit	$0
FluorideAdditional plan benefit	$0
Restorative dental careAdditional plan benefit	$0
Root canal treatment (endodontics)Additional plan benefit	$0
Gum treatment (periodontics)Additional plan benefit	$0
Removable dentures (prosthodontics)Additional plan benefit	$0
Fixed dental restorations (prosthodontics)Additional plan benefit	$0
Oral surgeryAdditional plan benefit	$0

Vision benefits

Vision benefits and member costs
Service	In-network	What to know
Medicare-covered eye exams	$0 Service-specific deductible No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0	Approval required No Referral required No
Medicare-covered eyewear	$0 Service-specific deductible No	Approval required No Referral required No
Contact lensesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglass lensesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglass framesAdditional plan benefit	$0	Approval required No Referral required No

Hearing benefits

Hearing benefits and member costs
Service	In-network	What to know
Medicare-covered hearing exams	$0 Service-specific deductible No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0	Approval required No Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$0 Service-specific deductible No	Approval required No Referral required No

Extra benefits

Extra benefits and member costs
Service	In-network	What to know
Supplemental acupunctureAdditional plan benefit	$0 Service-specific deductible No	Approval required Yes Referral required Yes
Over-the-counter health itemsAdditional plan benefit	$0 Service-specific deductible No
Limited-duration mealsAdditional plan benefit	$0 Service-specific deductible No	Approval required No Referral required No
Annual physical examAdditional plan benefit	$0 Service-specific deductible No	Approval required No Referral required No
Fitness benefitAdditional plan benefit	$0 Service-specific deductible No	Approval required Yes Referral required No

Allowances and optional benefits

Chiro and Acupuncture

One shared limit covers the listed services, not a separate allowance for each service.

Services sharing this allowance: Routine Chiropractic Care; Acupuncture Treatments
How benefits are provided: Claims Processing
Advance choice of benefits required: No
Shared limit on visits or trips: Yes
Indicate number of shared visits/trips: 12
How often this limit applies: Every year

OTC + SSBCI

One shared limit covers the listed services, not a separate allowance for each service.

Services sharing this allowance: Over-the-counter health items; Additional Benefits for SSBCI
Service categories that apply to the combined supplemental benefits group for Special Supplemental Benefits for Chronically Ill (SSBCI) package(s): Food and produce (SSBCI: Package 1); Support for daily living (SSBCI: Package 1); Home and Bathroom Safety Devices and Modifications (SSBCI: Package 1)
How benefits are provided: Debit Card
Advance choice of benefits required: No
Shared benefit limit: $197.00
How often this limit applies: Every one month
Are the benefits combined such that a single benefit maximum available to all enrollees in the benefit details section is extended to an SSBCI or MA UF benefit for eligible enrollees?: Yes
Shared limit on visits or trips: No

Benefits for qualifying members

Package 1

The plan must confirm eligibility, including any qualifying condition.

Qualifying conditions: Chronic alcohol use disorder and other substance use disorders (SUDs); Autoimmune disorders; Cancer; Cardiovascular disorders; Chronic heart failure; Dementia; Diabetes mellitus; Overweight, obesity, and metabolic syndrome; Chronic gastrointestinal disease; Chronic kidney disease (CKD); Severe hematologic disorders; HIV/AIDS; Chronic lung disorders; Chronic and disabling mental health conditions; Neurologic disorders; Stroke; Post-organ transplantation; Immunodeficiency and Immunosuppressive disorders; Conditions associated with cognitive impairment; Conditions with functional challenges; Chronic conditions that impair vision, hearing (deafness), taste, touch, and smell; Conditions that require continued therapy services in order for individuals to maintain or retain functioning; Other 1; Other 2
Qualifying conditions: Chronic Hypertension
Qualifying conditions: Chronic Hyperlipidemia
Included services: Food and produce; Pest control; Indoor Air Quality Equipment and Services; Support for daily living; Other 1 Non-Primarily Health Related Benefit; Home and Bathroom Safety Devices and Modifications
Applies to out-of-network or point-of-service care: No
Some package benefits are exempt from the deductible: No
Package limit: $0.00
How often this limit applies: Every month
How benefits are provided: Debit Card
Services sharing the package limit: Food and produce; Support for daily living; Home and Bathroom Safety Devices and Modifications

Prescription drug coverage

Costs shown are for initial coverage.

Drug deductible exceptions: Tier 1; Tier 2; Tier 6 are exempt from the deductible.

Standard retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard retail: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	100 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	25%	25%	25%
Tier 3Preferred Brand	25%	25%	25%
Tier 4Non-Preferred Drug	30%	30%	30%
Tier 5Specialty Tier	25%	Not listed	Not listed
Tier 6Select Care Drugs	$5.00	$10.00	$0.00

Mail-order and other pharmacies

Out-of-network pricing: You pay the standard retail copay or coinsurance, plus any difference between the pharmacy’s billed charge and the amount the plan allows at a standard retail pharmacy.

Standard mail order costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard mail order: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	100 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	25%	25%	25%
Tier 3Preferred Brand	25%	25%	25%
Tier 4Non-Preferred Drug	30%	30%	30%
Tier 5Specialty Tier	25%	Not listed	Not listed
Tier 6Select Care Drugs	$5.00	$10.00	$0.00

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier	31 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	25%
Tier 3Preferred Brand	25%
Tier 4Non-Preferred Drug	30%
Tier 5Specialty Tier	25%
Tier 6Select Care Drugs	$5.00

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier	30 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	25%
Tier 3Preferred Brand	25%
Tier 4Non-Preferred Drug	30%
Tier 5Specialty Tier	25%
Tier 6Select Care Drugs	$5.00

Drug coverage rules and exceptions

Tier 1: Preferred Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 2: Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 3: Preferred Brand

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 4: Non-Preferred Drug

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 5: Specialty Tier

Drugs included in this tier: Part D Drugs Only

Tier 6: Select Care Drugs

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Initial-coverage prices also apply to drugs exempt from the deductible: Yes

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.