Medicare Plan Lookup Official CMS data · Contract Year 2026
CMS 2026 data

2026 Medicare plan code

H0504-021

Medicare Plan

Blue Shield 65 Plus Plan 2 (HMO) · Blue Shield of California · HMO · Los Angeles and Orange Counties

Full CMS plan ID: H0504-021-000

H0504-021-000 is the full CMS identifier for the H0504-021 Medicare plan. Common searches include H0504 021 and H0504021.

Historical 2026 record. Benefits and service areas shown apply to that year.

2026

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2026 plan record

Blue Shield 65 Plus Plan 2 (HMO)

H0504-021-000 Los Angeles and Orange Counties HMO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Cost share not reported

02

Emergency transport

Ambulance

Ground · in-network$250 copay
Air · in-network20% coinsurance
03

Emergency services

Emergency room

$150 copay

Waived if admitted

04

Medical maximum

Maximum out-of-pocket

In-network$2,200
Combined in + outNot reported
05

Skilled care at home

Home health

In-networkCost share not reported
Out-of-networkNot separately reported
06

Monthly cost

Premium & giveback

Part C premium$0 / month
Consolidated C + D$0 / month

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-networkCost share not reported
Out-of-networkNot separately reported

Specialist

In-networkCost share not reported
Out-of-networkNot separately reported

Preventive care

In-networkCost share not reported
Out-of-networkNot separately reported
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-networkCost share not reported
Out-of-networkNot separately reported

Laboratory services

In-networkCost share not reported
Out-of-networkNot separately reported

X-rays & standard imaging

In-networkCost share not reported
Out-of-networkNot separately reported

MRI, CT & PET imaging

In-network20% coinsurance
Out-of-networkNot separately reported
Urgent & hospital care6 benefits

Urgent care

In-networkCost share not reported
Out-of-networkNot separately reported

Emergency room

In-network$150 copay
Out-of-networkNot separately reported

Ground ambulance

In-network$250 copay
Out-of-networkNot separately reported

Air ambulance

In-network20% coinsurance
Out-of-networkNot separately reported

Outpatient hospital

In-network$150 copay
Out-of-networkNot separately reported

Outpatient surgery / ASC

In-networkCost share not reported
Out-of-networkNot separately reported
Recovery & therapy5 benefits

Home health

In-networkCost share not reported
Out-of-networkNot separately reported

Skilled nursing facility

In-networkCost share not reported
Out-of-networkNot separately reported

Cardiac & pulmonary rehabilitation

In-network$30 copay
Out-of-networkNot separately reported

Occupational therapy

In-networkCost share not reported
Out-of-networkNot separately reported

Physical & speech therapy

In-networkCost share not reported
Out-of-networkNot separately reported
Behavioral health2 benefits

Mental health services

In-network$40 copay
Out-of-networkNot separately reported

Substance use treatment

In-network$40 copay
Out-of-networkNot separately reported
Specialty care2 benefits

Podiatry

In-networkCost share not reported
Out-of-networkNot separately reported

Chiropractic

In-networkCost share not reported
Out-of-networkNot separately reported
Supplemental benefits7 benefits

Dental

In-network$0–$16 copay
Out-of-networkNot separately reported

Vision

In-network$20 copay
Out-of-networkNot separately reported

Hearing

In-networkCost share not reported
Out-of-networkNot separately reported

Transportation

In-networkCost share not reported
Out-of-networkNot separately reported

Fitness & wellness

In-networkCost share not reported
Out-of-networkNot separately reported

Over-the-counter allowance

Not reported in this CMS export

Not reported in this CMS export

Meals

Not reported in this CMS export

Not reported in this CMS export

Plan costs & rulesCoverage overview

Premium & Part B giveback

$0 Part C premium / month · Part B giveback not separately reported

Maximum out-of-pocket (MOOP)

In-network$2,200
Combined in + outNot reported

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Network & referrals

HMO · Referrals: Required for some services · Out-of-network coverage: No

Prescription drugs5 tiers

Part D deductible

Not reported

Drug tier 1

$5 retail copay · 30-day supply

Drug tier 2

$18 retail copay · 30-day supply

Drug tier 3

20% retail coinsurance · 30-day supply

Drug tier 4

25% retail coinsurance · 30-day supply

Drug tier 5

29% retail coinsurance · 30-day supply

Using this plan

Understand H0504-021-000

Plain-language context built from this plan’s 2026 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.

Plan at a glance

A quick read on this plan

Blue Shield 65 Plus Plan 2 (HMO) is a 2026 HMO offered by Blue Shield of California in Los Angeles and Orange Counties. The CMS record does not indicate routine out-of-network coverage. Referrals are required for some services.

Common benefit costs

What you may pay

These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.

Routine care

Primary care physician
Cost share not reported
Specialist
Cost share not reported
Laboratory services
Cost share not reported

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
Cost share not reported
MRI, CT & PET imaging
20% coinsurance
Outpatient hospital
$150 copay

The service setting and billing details can change what you pay.

Emergency & hospital care

Emergency room
$150 copay

Actual costs depend on the care received and plan rules.

Helpful context

Terms worth knowing

Maximum out-of-pocket (MOOP)

This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.

Availability

Who can enroll

Service area
Los Angeles and Orange Counties (CA)
Plan type
HMO
Contract / plan
H0504-021
Coverage year
2026

Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.

Supplemental coverage

Extra benefits reported

Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.

Dental$0–$16 copay
Vision$20 copay
HearingCost share not reported
Fitness & wellnessCost share not reported
TransportationCost share not reported

Plan-specific answers

Frequently asked questions

Where is H0504-021-000 available?

Blue Shield 65 Plus Plan 2 (HMO) is listed for Los Angeles and Orange Counties (CA). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H0504-021-000?

The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $2,200. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H0504-021-000?

The listed consolidated Part C and Part D premium is $0 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H0504-021-000?

The plan record lists $150 copay, waived when an admission meets the plan's stated timing rule.

Does H0504-021-000 report extra benefits?

Yes. CMS reports dental, vision, hearing, fitness & wellness, transportation. See the detailed benefit rows and official plan documents for limits and conditions.

Source trail

Official CMS, Contract Year 2026

Plan identity and benefits come from CMS PBP data. Premium and MOOP figures are cross-checked against the August 2026 Landscape release; county identity is sourced from segment-level Landscape rows and stable codes are enriched from the aligned MA contract service-area release where matched. Quick-reference values should be confirmed in 2026 official plan documents.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H0504-021-000 fits

Full CMS plan ID
H0504-021-000
Contract
H0504
Base plan code
H0504-021
Segment
000
Carrier
Blue Shield of California
Plan type
HMO
Service area
Los Angeles and Orange Counties (CA)

County/service-area foundation

CMS service-area entries

Named county entries are tied to this exact contract, plan, and segment in CMS Landscape data. County codes are enriched from the aligned CMS contract service-area release where a match exists.

  • Los Angeles, CA
  • Los Angeles, CA
  • Orange, CA

Same CMS contract

H0504-015-000 Blue Shield 65 Plus (HMO) Los Angeles and Orange Counties · HMO H0504-017-000 Blue Shield 65 Plus (HMO) San Bernardino County · HMO H0504-026-000 Blue Shield 65 Plus (HMO) Riverside County · HMO H0504-028-000 Blue Shield 65 Plus (HMO) San Diego County · HMO H0504-038-000 Blue Shield 65 Plus (HMO) Kern County · HMO H0504-039-000 Blue Shield 65 Plus (HMO) San Luis Obispo and Santa Barbara Counties · HMO H0504-040-000 Blue Shield 65 Plus Choice Plan (HMO) Riverside and San Bernardino Counties · HMO H0504-041-000 Blue Shield Inspire (HMO) Alameda and San Mateo Counties · HMO

About this code

What H0504-021-000 identifies

H0504-021-000 is a Contract Year 2026 Medicare plan segment code. Searches written as H0504-021, H0504 021, or the compact full CMS ID H0504021000 refer to this plan or its base plan code.

Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.