Page 74 - Cover Letter & Evaluation for Michael Novotny

6/9/2018 Your Medicare Health Plan Details

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Your Plan Details
Zip Code: 92886
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits,
drug costs and more coverage and star ratings. Important Coverage Information

Symbols
A process through which the physician or other health care provider is required to obtain advance approval from the
plan that payment will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to
a particular item or service, the enrollee is not responsible for obtaining (prior) authorization.
A process through which the enrollee’s primary care physician or other network physician (depending on the plan
policy) permits or instructs the enrollee to obtain an item or service from another physician or other provider type.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage
* Estimated

Alignment Health Plan My 1100 W Town and Country Rd Overall Star Rating: [?] Enroll
Suite 1300
Choice (HMO)
Orange, CA 92868
(H3815-001-0) 4.5 out of 5 stars
Members:
Organization: Alignment Health Plan 1-866-634-2247 ext: 5550
711 (TTY/TDD)
Plan Type: HMO
Non Members:
1-888-979-2247 ext: 5551
711 (TTY/TDD)

Benefits Highlights

Monthly health plan premium $0.00

Health plan deductible $0

Other health plan deductibles?
In-Network: No

Maximum out-of-pocket enrollee $3,400 In-network
responsibility (does not include
prescription drugs)
Optional supplemental benefits [?] No

Inpatient hospital coverage $50 for days 1 through 3
$0 for days 4 through 90
$0 for days 91 and beyond

Outpatient hospital coverage $100 per visit

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