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

2026 Medicare plan code

H2775-116

Medicare Plan

Wellcare Patriot Giveback Open (PPO) · Wellcare · Local PPO · Select counties in ME

Full CMS plan ID: H2775-116-000

H2775-116-000 is the full CMS identifier for the H2775-116 Medicare plan. Common searches include H2775 116 and H2775116.

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

Wellcare Patriot Giveback Open (PPO)

H2775-116-000 Select counties in ME Local PPO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–6 $400 / day
Days 7–90 $0 / day
Total of listed copays · 6 charged days $2,400
02

Emergency transport

Ambulance

Ground · in-network$300 copay
Air · in-network$300 copay
03

Emergency services

Emergency room

$115 copay

Waived if admitted within 24 hours

04

Medical maximum

Maximum out-of-pocket

In-network$9,250
Combined in + out$13,900
05

Skilled care at home

Home health

In-network$0 copay
Out-of-network40% coinsurance
06

Monthly cost

Premium & giveback

Part C premium$0 / month
Consolidated C + DNot reported

Plan name references a giveback; amount is not available in these CMS exports.

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-network$0 copay
Out-of-network$25 copay

Specialist

In-network$35 copay
Out-of-network$60 copay

Preventive care

In-network$0 copay
Out-of-network$0 copay
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-network$0–$100 copay
Out-of-network40% coinsurance

Laboratory services

In-network$0–$50 copay
Out-of-network40% coinsurance

X-rays & standard imaging

In-network0%–30% coinsurance
Out-of-network40% coinsurance

MRI, CT & PET imaging

In-network20% coinsurance
Out-of-network40% coinsurance
Urgent & hospital care6 benefits

Urgent care

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

Emergency room

In-network$115 copay
Out-of-networkNot separately reported

Ground ambulance

In-network$300 copay
Out-of-network$300 copay

Air ambulance

In-network$300 copay
Out-of-network$300 copay

Outpatient hospital

In-network$0 copay + 30% coinsurance
Out-of-network40% coinsurance

Outpatient surgery / ASC

In-network$250 copay
Out-of-network40% coinsurance
Recovery & therapy5 benefits

Home health

In-network$0 copay
Out-of-network40% coinsurance

Skilled nursing facility

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

Cardiac & pulmonary rehabilitation

In-network$30 copay
Out-of-network40% coinsurance

Occupational therapy

In-network$35 copay
Out-of-network40% coinsurance

Physical & speech therapy

In-network$35 copay
Out-of-network40% coinsurance
Behavioral health2 benefits

Mental health services

In-network$105 copay
Out-of-network40% coinsurance

Substance use treatment

In-network$105 copay
Out-of-network40% coinsurance
Specialty care2 benefits

Podiatry

In-network$35 copay
Out-of-network40% coinsurance

Chiropractic

In-network$15 copay
Out-of-network40% coinsurance
Supplemental benefits7 benefits

Dental

In-network$35 copay
Out-of-network$60 copay

Vision

In-network$0 copay
Out-of-network40% coinsurance

Hearing

In-network$0 copay
Out-of-network40% coinsurance

Transportation

Not reported in this CMS export

Not reported in this CMS export

Fitness & wellness

In-network$0 copay
Out-of-network$0 copay

Over-the-counter allowance

In-network$0 copay
Out-of-network$0 copay

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 · Plan name references a giveback; amount is not available in these CMS exports.

Maximum out-of-pocket (MOOP)

In-network$9,250
Combined in + out$13,900

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Network & referrals

Local PPO · Referrals: Required for some services · Out-of-network coverage: Yes

Prescription drugs0 tiers

Part D deductible

CMS did not publish a supported Part D deductible amount

Using this plan

Understand H2775-116-000

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

Wellcare Patriot Giveback Open (PPO) is a 2026 Local PPO offered by Wellcare in Select counties in ME. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. Referrals are required for some services. Its listed inpatient copay stages total $2,400 across 6 charged days.

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
$0 copay
Specialist
$35 copay
Laboratory services
$0–$50 copay

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
$0–$100 copay
MRI, CT & PET imaging
20% coinsurance
Outpatient hospital
$0 copay + 30% coinsurance

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

Emergency & hospital care

Emergency room
$115 copay
Listed inpatient stages
$2,400 total

6 charged inpatient days are included in the calculated total. 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.

Part B premium reduction (“giveback”)

A giveback may reduce the amount you pay toward Medicare Part B; it is not usually paid to you as cash. The CMS record notes: Plan name references a giveback; amount is not available in these CMS exports.

Availability

Who can enroll

Service area
Select counties in ME (ME)
Plan type
Local PPO
Contract / plan
H2775-116
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$35 copay
Vision$0 copay
Hearing$0 copay
Over-the-counter allowance$0 copay
Fitness & wellness$0 copay

Plan-specific answers

Frequently asked questions

Where is H2775-116-000 available?

Wellcare Patriot Giveback Open (PPO) is listed for Select counties in ME (ME). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H2775-116-000?

The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $9,250. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H2775-116-000?

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

What does an emergency room visit cost on H2775-116-000?

The plan record lists $115 copay, waived when an admission meets the plan's stated timing rule.

Does H2775-116-000 report extra benefits?

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

Carrier-hosted source material

Official plan documents

An exact direct document has not been verified for this plan yet. Use the carrier's document finder and confirm H2775-116-000 before relying on a document.

Wellcare plan document finder Search on the official carrier site ↗

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 H2775-116-000 fits

Full CMS plan ID
H2775-116-000
Contract
H2775
Base plan code
H2775-116
Segment
000
Carrier
Wellcare
Plan type
Local PPO
Service area
Select counties in ME (ME)

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.

  • Androscoggin, ME
  • Aroostook, ME
  • Cumberland, ME
  • Franklin, ME
  • Hancock, ME
  • Kennebec, ME
  • Knox, ME
  • Lincoln, ME
  • Oxford, ME
  • Penobscot, ME
  • Piscataquis, ME
  • Sagadahoc, ME

3 additional service-area entries are retained in the data record.

Same CMS contract

H2775-109-000 Wellcare Low Premium Open (PPO) Select counties in ME · Local PPO H2775-115-000 Wellcare Dual Access Open (PPO D-SNP) Select counties in ME · Local PPO H2775-106-000 Wellcare Simple Open (PPO) Select counties in NY · Local PPO H2775-111-000 Wellcare Giveback Open (PPO) Select counties in NY · Local PPO H2775-112-000 Wellcare Dual Access Open (PPO D-SNP) Select counties in NY · Local PPO H2775-113-000 Wellcare Assist Open (PPO) Select counties in NY · Local PPO

About this code

What H2775-116-000 identifies

H2775-116-000 is a Contract Year 2026 Medicare plan segment code. Searches written as H2775-116, H2775 116, or the compact full CMS ID H2775116000 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.