2019 Alignment Health Plan CalPlus (HMO) H3815-009 By Alignment Health Plan

2019 Medicare Advantage Plan Services for
Alignment Health Plan CalPlus (HMO)


Alignment Health Plan CalPlus (HMO) H3815-009 is a 2019 Medicare Advantage or Medicare Part-C plan by Alignment Health Plan available to residents in California. This plan includes additional Medicare prescription drug (Part-D) coverage. The Alignment Health Plan CalPlus (HMO) has a monthly premium of $30.50 and has an in-network Maximum Out-of-Pocket limit of $6,700 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,700 out of pocket. This can be a extremely nice safety net.

Alignment Health Plan CalPlus (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered by the plan.

Alignment Health Plan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Alignment Health Plan CalPlus (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Alignment Health Plan and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Alignment Health Plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.



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2019 Alignment Health Plan Medicare Advantage Plan Details

Name:
Alignment Health Plan CalPlus (HMO)
ID:
H3815-009
Provider:Alignment Health Plan
Year:2019
Type: Local HMO
Monthly Premium C+D: $30.50
Part C Premium:$0.00
MOOP: $6,700
Part D (Drug) Premium:$30.50
Part D Supplemental Premium$0.00
Total Part D Premium:$30.50
Drug Deductible:$415.00
Tiers with No Deductible:0
Gap Coverage:No
Initial Coverage Limit:$3820
Benchmark:below the regional benchmark
Type of Medicare Health:Actuarially Equivalent Standard
Drug Benefit Type:Basic






Part-C Premium

Alignment Health Plan plan charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.



Part-D Deductible and Premium

Alignment Health Plan CalPlus (HMO) has a monthly drug premium of $30.50 and a $415.00 drug deductible. This Alignment Health Plan plan offers a $30.50 Part D Basic Premium that is below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Alignment Health Plan above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $30.50. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.



Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Alignment Health Plan CalPlus (HMO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $7.60 for 75% low income subsidy $15.20 for 50% and $22.90 for 25%.



Full LIS Premium:$0.00
75% LIS Premium:$7.60
50% LIS Premium:$15.20
25% LIS Premium:$22.90


Gap Coverage

In 2019 once you and your plan provider have spent $3820 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for brand-name drugs and 37% on generic drugs unless your plan offers additional coverage. This Alignment Health Plan plan does not offer additional coverage through the gap.





Plan Services




Health plan deductible


$0



Emergency care/Urgent care


Emergency 20% per visit (always covered)
Urgent care 20% per visit (always covered)



Diagnostic procedures/lab services/imaging


Diagnostic tests and procedures 20%
Lab services 20%
Diagnostic radiology services (e.g., MRI) $0 copay
Outpatient x-rays $0 copay



Hearing


Hearing exam $0 copay
Fitting/evaluation $0 copay
Hearing aids $0 copay



Preventive dental


Oral exam $0 copay
Cleaning $0 copay
Fluoride treatment $0-20
Dental x-ray(s) $0-30



Comprehensive dental


Non-routine services $0 copay
Diagnostic services $0-30
Restorative services $20-350
Endodontics $15-375
Periodontics $15-375
Extractions $25-140
Prosthodontics, other oral/maxillofacial surgery, other services $20-425



Vision


Routine eye exam $0 copay
Other Not covered
Contact lenses $0 copay
Eyeglasses (frames and lenses) $0 copay
Eyeglass frames $0 copay
Eyeglass lenses $0 copay
Upgrades $0 copay



Mental health services


Inpatient hospital - psychiatric Coming soon
Outpatient group therapy visit with a psychiatrist 20%
Outpatient individual therapy visit with a psychiatrist 20%
Outpatient group therapy visit 20%
Outpatient individual therapy visit 20%



Skilled Nursing Facility


Coming soon



Rehabilitation services


Occupational therapy visit 20%
Physical therapy and speech and language therapy visit 20%



Ground ambulance


20%



Other health plan deductibles?


In-Network No



Transportation


$0 copay



Foot care (podiatry services)


Foot exams and treatment $0 copay
Routine foot care Not covered



Medical equipment/supplies


Durable medical equipment (e.g., wheelchairs, oxygen) 20% per item
Prosthetics (e.g., braces, artificial limbs) 20% per item
Diabetes supplies $0 copay



Wellness programs (e.g., fitness, nursing hotline)


Covered



Medicare Part B drugs


Chemotherapy 20%
Other Part B drugs 20%



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)


$6,700 In-network



Optional supplemental benefits


No



Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?


In-Network No



Inpatient hospital coverage


Coming soon



Outpatient hospital coverage


20% per visit



Doctor visits


Primary $0 copay
Specialist $0 copay



Preventive care


$0 copay




Ratings for Alignment Health Plan CalPlus (HMO) H3815

2018 Overall Rating
Part C Summary Rating
Part D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Improving Physical
Improving Mental Health
Monitoring Physical Activity
Adult BMI Assessment


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Pain Screening
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Plan All-Cause Readmissions
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Timely Care and Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Alignment Health Plan CalPlus (HMO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for Alignment Health Plan CalPlus (HMO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Alignment Health Plan CalPlus (HMO) Drug Plan Customer Service ratings

Total Rating
Call Center, TTY, Foreign Language
Appeals Auto
Appeals Upheld


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes


Coverage Area for Alignment Health Plan CalPlus (HMO)

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Source: CMS.
Data as of September 2, 2018.
Star Rating as of October 10, 2018.
For More Information on Ratings Please See the CMS Tech Notes.
Notes: Data are subject to change as contracts are finalized. For 2019, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit. Includes 2019 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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