2023 Alignment Health AVA (PPO)

Alignment Health AVA (PPO) H9614-001 is a 2023 Medicare Advantage Plan or Part-C by Alignment Health Plan available to residents in Texas and Arizona. This plan includes extra prescription drug (Part-D) coverage. Alignment Health Plan Alignment Health AVA (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $3,900 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $3,900 out-of-pocket. This can be an extremely nice safety net.

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 AVA (PPO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Alignment Health Plan and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all the benefits of Original Medicare from Alignment Health Plan except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in Texas or Medicare Advantage in Arizona.



2023 Alignment Health Plan Medicare Advantage Plan Overview

Name:Alignment Health AVA (PPO)
Plan ID:H9614 001 0
Provider:Alignment Health Plan
Year:2023
Type:Local PPO
Combined Premium (C+D):$0/mo
Part C Premium:$0/mo
MOOP:$3,900/yr
Part D (Drug) Premium:$0/mo
Part D Supplemental Premium$0/mo
Total Part D Premium:$0/mo
Drug Deductible:$0/yr
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:Not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H9614-001




What type of plan is Alignment Health AVA (PPO)

Alignment Health AVA (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network, but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.



How much does Alignment Health AVA (PPO) cost?


Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Alignment Health Plan charges a $0 consolidated premium. The Part C premium is $0 this charge 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

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Alignment Health AVA (PPO) has a monthly drug premium of $0 and a $0 drug deductible. This Alignment Health Plan plan offers a $0 Part-D Basic Premium that is Not 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. This Premium covers any enhanced plan benefits offered by Alignment Health Plan above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $0. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.


Alignment Health Plan Gap Coverage

In 2023 once you and your plan provider have spent $4660 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 prescription drugs unless your plan offers extra coverage. This Alignment Health Plan plan does offer extra coverage through the gap.


MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Alignment Health AVA (PPO) by Alignment Health Plan MOOP is $3,900. Once you spend $3,900 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.



Formulary and Drug Coverage

Alignment Health AVA (PPO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 NA $0
Tier 2 NA $5
Tier 3 NA $40
Tier 4 NA $100
Tier 5 NA 33%
Tier 6 NA $5

The complete Alignment Health AVA (PPO) Formulary.
*Initial Coverage Phase and 30 day supply





2023 Summary of Benefits


The benefit information provided is a summary of what Alignment Health AVA (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Alignment Health Plan helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

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



Contact lenses


In-Network Vision$0 copay
Out-of-Network Vision50% coinsurance



Eyeglass frames


Out-of-Network Vision50% coinsurance
In-Network Vision$0 copay



Eyeglass lenses


In-Network Vision$0 copay
Out-of-Network Vision50% coinsurance



Eyeglasses (frames and lenses)


In-Network Vision$0 copay
Out-of-Network Vision50% coinsurance



Other


VisionNot covered



Routine eye exam


Out-of-Network Vision30% coinsurance
In-Network Vision$0 copay



Upgrades


VisionNot covered




TransportationNot covered
Out-of-Network Skilled Nursing Facility30% per stay
In-Network Skilled Nursing Facility$0 per day for days 1 through 20
$100 per day for days 21 through 51
$0 per day for days 52 through 100



Occupational therapy visit


In-Network Rehabilitation services$0 copay
Out-of-Network Rehabilitation services30% coinsurance



Physical therapy and speech and language therapy visit


In-Network Rehabilitation services$0 copay
Out-of-Network Rehabilitation services30% coinsurance



Cleaning


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental30% coinsurance



Dental x-ray(s)


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental30% coinsurance



Fluoride treatment


Out-of-Network Preventive dental30% coinsurance
In-Network Preventive dental$0 copay



Oral exam


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental30% coinsurance




In-Network Preventive care$0 copay
Out-of-Network Preventive care30% coinsurance
In-Network Outpatient hospital coverage$165 copay per visit
Out-of-Network Outpatient hospital coverage25% coinsurance per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsYes



Inpatient hospital - psychiatric


In-Network Mental health services$120 per day for days 1 through 10
$0 per day for days 11 through 90
$0 per day for days 91 through 130
Out-of-Network Mental health services30% per stay



Outpatient group therapy visit


In-Network Mental health services$0 copay
Out-of-Network Mental health services30% coinsurance



Outpatient group therapy visit with a psychiatrist


Out-of-Network Mental health services30% coinsurance
In-Network Mental health services$40 copay



Outpatient individual therapy visit


In-Network Mental health services$0 copay
Out-of-Network Mental health services30% coinsurance



Outpatient individual therapy visit with a psychiatrist


In-Network Mental health services$40 copay
Out-of-Network Mental health services30% coinsurance



Chemotherapy


Out-of-Network Medicare Part B drugs30% coinsurance
In-Network Medicare Part B drugs20% coinsurance



Other Part B drugs


Out-of-Network Medicare Part B drugs30% coinsurance
In-Network Medicare Part B drugs20% coinsurance



Diabetes supplies


In-Network Medical equipment/supplies$0 copay
Out-of-Network Medical equipment/supplies30% coinsurance per item



Durable medical equipment (e.g., wheelchairs, oxygen)


In-Network Medical equipment/supplies0-20% coinsurance per item
Out-of-Network Medical equipment/supplies30% coinsurance per item



Prosthetics (e.g., braces, artificial limbs)


In-Network Medical equipment/supplies20% coinsurance per item
Out-of-Network Medical equipment/supplies30% coinsurance per item




Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$6,500 In and Out-of-network
$3,900 In-network
Out-of-Network Inpatient hospital coverage30% per stay
In-Network Inpatient hospital coverage$150 per day for days 1 through 3
$0 per day for days 4 through 90
$0 per day for days 91 and beyond



Fitting/evaluation


In-Network Hearing$0 copay
Out-of-Network Hearing30% coinsurance



Hearing aids - inner ear


HearingNot covered



Hearing aids - outer ear


HearingNot covered



Hearing aids - over the ear


HearingNot covered



Hearing exam


In-Network Hearing$0 copay
Out-of-Network Hearing30% coinsurance




Health plan deductible$0
In-Network Ground ambulance$250 copay
Out-of-Network Ground ambulance30% coinsurance



Foot exams and treatment


In-Network Foot care (podiatry services)$0 copay
Out-of-Network Foot care (podiatry services)30% coinsurance



Routine foot care


Foot care (podiatry services)Not covered



Emergency


Emergency care/Urgent care$85 copay per visit (always covered)



Urgent care


Emergency care/Urgent care$20 copay per visit (always covered)



Primary


In-Network Doctor visits$5 copay per visit
Out-of-Network Doctor visits$40 copay per visit



Specialist


Out-of-Network Doctor visits$50 copay per visit
In-Network Doctor visits$20 copay per visit



Diagnostic radiology services (e.g., MRI)


Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance
In-Network Diagnostic procedures/lab services/imaging$150 copay



Diagnostic tests and procedures


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance



Lab services


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance



Outpatient x-rays


Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance
In-Network Diagnostic procedures/lab services/imaging$15 copay



Diagnostic services


Comprehensive dentalNot covered



Endodontics


Comprehensive dentalNot covered



Extractions


Comprehensive dentalNot covered



Non-routine services


Comprehensive dentalNot covered



Periodontics


In-Network Comprehensive dental$20 copay
Out-of-Network Comprehensive dental30% coinsurance



Prosthodontics, other oral/maxillofacial surgery, other services


Comprehensive dentalNot covered



Restorative services


In-Network Comprehensive dental$20 copay
Out-of-Network Comprehensive dental30% coinsurance




In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?No




Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Alignment Health AVA (PPO) requires you to live in that plan’s service area. The service area is listed below:



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How much does Alignment Health AVA (PPO) cost?

Alignment Health Plan charges a $0 consolidated monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage of Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

How much is Alignment Health AVA (PPO) MOOP?

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Alignment Health AVA (PPO) by Alignment Health Plan MOOP is $3,900. Once you spend $3,900 you will pay nothing for Part A or Part B covered services.

What type of plan is Alignment Health AVA (PPO)?

Alignment Health AVA (PPO) is a Local PPO. A (PPO) is a Medicare plan that has contracts with a network of preferred providers. You do not need to select a primary care physician and you do not need referrals to see other providers in the network.



Source:CMS. Data as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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