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

2026 Medicare plan code

H3864-036

Medicare Plan

PacificSource Medicare Essentials Choice Rx 36 (HMO-POS) · PacificSource Medicare · HMOPOS · Select Oregon Counties

Full CMS plan ID: H3864-036-000

H3864-036-000 is the full CMS identifier for the H3864-036 Medicare plan. Common searches include H3864 036 and H3864036.

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

PacificSource Medicare Essentials Choice Rx 36 (HMO-POS)

H3864-036-000 Select Oregon Counties HMOPOS

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–7 $425 / day
Days 8–90 $0 / day
Total of listed copays · 7 charged days $2,975
02

Emergency transport

Ambulance

Ground · in-network$350 copay
Air · in-network$350 copay

Ground ambulance: In-network: cost sharing varies by a CMS plan-defined group; Air ambulance: In-network: cost sharing varies by a CMS plan-defined group

03

Emergency services

Emergency room

$120 copay

Waived if admitted within 72 hours

04

Medical maximum

Maximum out-of-pocket

In-network$6,500
Combined in + out$8,950
05

Skilled care at home

Home health

In-networkVerify in plan documents
Out-of-networkNot separately reported
06

Monthly cost

Premium & giveback

Part C premium$28 / month
Consolidated C + D$28 / month

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

Verify in plan documents
In-network$0–$15 copay
Out-of-networkNot separately reported

Specialist

Verify in plan documents
In-network$0–$35 copay
Out-of-networkNot separately reported

Preventive care

Verify in plan documents
In-network20% coinsurance
Out-of-networkNot separately reported
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

Verify in plan documents
In-network$40 copay + 20% coinsurance
Out-of-networkNot separately reported

Laboratory services

Verify in plan documents
In-network0%–20% coinsurance
Out-of-networkNot separately reported

X-rays & standard imaging

Verify in plan documents
In-network$0–$450 copay
Out-of-networkNot separately reported

MRI, CT & PET imaging

Verify in plan documents
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$120 copay
Out-of-networkNot separately reported

Ground ambulance

Verify in plan documents
In-network$350 copay
Out-of-networkNot separately reported

Air ambulance

Verify in plan documents
In-network$350 copay
Out-of-networkNot separately reported

Outpatient hospital

Verify in plan documents
In-network$0–$425 copay
Out-of-networkNot separately reported

Outpatient surgery / ASC

Verify in plan documents
In-network$0–$425 copay
Out-of-networkNot separately reported
Recovery & therapy5 benefits

Home health

Verify in plan documents
In-networkVerify in plan documents
Out-of-networkNot separately reported

Skilled nursing facility

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

Cardiac & pulmonary rehabilitation

Verify in plan documents
In-network$35 copay
Out-of-networkNot separately reported

Occupational therapy

Verify in plan documents
In-network$40 copay
Out-of-networkNot separately reported

Physical & speech therapy

Verify in plan documents
In-network$40 copay
Out-of-networkNot separately reported
Behavioral health2 benefits

Mental health services

Verify in plan documents
In-network$55 copay
Out-of-networkNot separately reported

Substance use treatment

Verify in plan documents
In-network$55 copay
Out-of-networkNot separately reported
Specialty care2 benefits

Podiatry

Verify in plan documents
In-network$35 copay
Out-of-networkNot separately reported

Chiropractic

Verify in plan documents
In-network$25 copay
Out-of-networkNot separately reported
Supplemental benefits7 benefits

Dental

Verify in plan documents
In-network$40 copay
Out-of-networkNot separately reported

Vision

Verify in plan documents
In-networkCost share not reported
Out-of-networkNot separately reported

Hearing

Verify in plan documents
In-network$599–$999 copay
Out-of-networkNot separately reported

Transportation

Not reported in this CMS export

Not reported in this CMS export

Fitness & wellness

Verify in plan documents
In-networkVerify in plan documents
Out-of-networkNot separately reported

Over-the-counter allowance

Not reported in this CMS export

Not reported in this CMS export

Meals

Verify in plan documents
In-networkVerify in plan documents
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview

Premium & Part B giveback

$28 Part C premium / month · Part B giveback not separately reported

Maximum out-of-pocket (MOOP)

In-network$6,500
Combined in + out$8,950

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Network & referrals

HMOPOS · Referrals: Not required · Out-of-network coverage: Not reported

Prescription drugs5 tiers

Part D deductible

Not reported

Drug tier 1

$0 retail copay · 30-day supply

Drug tier 2

$6 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

27% retail coinsurance · 30-day supply

Using this plan

Understand H3864-036-000

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

PacificSource Medicare Essentials Choice Rx 36 (HMO-POS) is a 2026 HMOPOS offered by PacificSource Medicare in Select Oregon Counties. The plan record does not require referrals. Its listed inpatient copay stages total $2,975 across 7 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–$15 copay
Specialist
$0–$35 copay
Laboratory services
0%–20% coinsurance

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
$40 copay + 20% coinsurance
MRI, CT & PET imaging
20% coinsurance
Outpatient hospital
$0–$425 copay

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

Emergency & hospital care

Emergency room
$120 copay
Listed inpatient stages
$2,975 total

7 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.

Availability

Who can enroll

Service area
Select Oregon Counties (OR)
Plan type
HMOPOS
Contract / plan
H3864-036
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$40 copay
VisionCost share not reported
Hearing$599–$999 copay
Fitness & wellnessVerify in plan documents
MealsVerify in plan documents

Plan-specific answers

Frequently asked questions

Where is H3864-036-000 available?

PacificSource Medicare Essentials Choice Rx 36 (HMO-POS) is listed for Select Oregon Counties (OR). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H3864-036-000?

The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $6,500. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H3864-036-000?

The listed consolidated Part C and Part D premium is $28 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H3864-036-000?

The plan record lists $120 copay, waived when an admission meets the plan's stated timing rule.

Does H3864-036-000 report extra benefits?

Yes. CMS reports dental, vision, hearing, fitness & wellness, meals. 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 H3864-036-000 fits

Full CMS plan ID
H3864-036-000
Contract
H3864
Base plan code
H3864-036
Segment
000
Carrier
PacificSource Medicare
Plan type
HMOPOS
Service area
Select Oregon Counties (OR)

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.

  • Crook, OR
  • Deschutes, OR
  • Hood River, OR
  • Jefferson, OR
  • Klamath, OR · employer/group only
  • Klamath, OR · partial county
  • Lane, OR
  • Sherman, OR
  • Wasco, OR

Same CMS contract

H3864-002-000 PacificSource Medicare Essentials Choice 2 (HMO-POS) Select Oregon Counties · HMOPOS H3864-014-000 PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) Select Oregon Counties · HMOPOS H3864-030-000 PacificSource Medicare MyCare Choice 30 (HMO-POS) Select Idaho, Montana, and Oregon Counties · HMOPOS H3864-805-000 PacificSource Medicare Essentials 805 (HMO-POS) Statewide - Idaho, Montana, and Oregon · HMOPOS H3864-806-000 PacificSource Medicare Essentials Rx 806 (HMO-POS) Statewide - Idaho, Montana, and Oregon · HMOPOS H3864-006-000 PacificSource Medicare Essentials Rx 6 (HMO) Select Oregon Counties · HMO H3864-027-000 PacificSource Medicare Essentials Rx 27 (HMO) Select Oregon Counties · HMO H3864-040-000 PacificSource Medicare MyCare Rx 40 (HMO) Select Oregon Counties · HMO

About this code

What H3864-036-000 identifies

H3864-036-000 is a Contract Year 2026 Medicare plan segment code. Searches written as H3864-036, H3864 036, or the compact full CMS ID H3864036000 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.