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

2026 Medicare plan code

H5828-016

Medicare Plan

Wellpoint Medicare Advantage 2 (HMO-POS) · Wellpoint · HMOPOS · Select counties in Tennessee

Full CMS plan ID: H5828-016-000

H5828-016-000 is the full CMS identifier for the H5828-016 Medicare plan. Common searches include H5828 016 and H5828016.

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

Wellpoint Medicare Advantage 2 (HMO-POS)

H5828-016-000 Select counties in Tennessee HMOPOS

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–6 $350 / day
Days 7–90 $0 / day
Total of listed copays · 6 charged days $2,100
02

Emergency transport

Ambulance

Ground · in-network$325 copay
Air · in-network$325 copay
03

Emergency services

Emergency room

$130 copay

04

Medical maximum

Maximum out-of-pocket

In-network$6,460
Combined in + outNot reported
05

Skilled care at home

Home health

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

Specialist

In-network$45 copay
Out-of-networkNot separately reported

Preventive care

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

Diagnostic procedures & tests

In-network$0–$150 copay
Out-of-networkNot separately reported

Laboratory services

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

X-rays & standard imaging

In-network$50–$350 copay
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$130 copay
Out-of-networkNot separately reported

Ground ambulance

In-network$325 copay
Out-of-networkNot separately reported

Air ambulance

In-network$325 copay
Out-of-networkNot separately reported

Outpatient hospital

In-network$0–$350 copay
Out-of-networkNot separately reported

Outpatient surgery / ASC

In-network$0–$300 copay
Out-of-networkNot separately reported
Recovery & therapy5 benefits

Home health

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

Skilled nursing facility

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

Cardiac & pulmonary rehabilitation

In-network$35 copay
Out-of-networkNot separately reported

Occupational therapy

In-network$45 copay
Out-of-networkNot separately reported

Physical & speech therapy

In-network$45 copay
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-network$0 copay
Out-of-networkNot separately reported

Chiropractic

In-network$15 copay
Out-of-networkNot separately reported
Supplemental benefits7 benefits

Dental

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

Vision

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

Hearing

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

Transportation

Not reported in this CMS export

Not reported in this CMS export

Fitness & wellness

Not reported in this CMS export

Not reported in this CMS export

Over-the-counter allowance

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

Meals

In-network$0 copay
Out-of-networkNot separately reported
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$6,460
Combined in + outNot reported

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

$10 retail copay · 30-day supply

Drug tier 3

25% retail coinsurance · 30-day supply

Drug tier 4

30% retail coinsurance · 30-day supply

Drug tier 5

30% retail coinsurance · 30-day supply

Using this plan

Understand H5828-016-000

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

Wellpoint Medicare Advantage 2 (HMO-POS) is a 2026 HMOPOS offered by Wellpoint in Select counties in Tennessee. The plan record does not require referrals. Its listed inpatient copay stages total $2,100 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
$45 copay
Laboratory services
$0 copay

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
$0–$150 copay
MRI, CT & PET imaging
20% coinsurance
Outpatient hospital
$0–$350 copay

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

Emergency & hospital care

Emergency room
$130 copay
Listed inpatient stages
$2,100 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.

Availability

Who can enroll

Service area
Select counties in Tennessee (TN)
Plan type
HMOPOS
Contract / plan
H5828-016
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 copay
Vision$0 copay
Hearing$0 copay
Over-the-counter allowance$0 copay
Meals$0 copay

Plan-specific answers

Frequently asked questions

Where is H5828-016-000 available?

Wellpoint Medicare Advantage 2 (HMO-POS) is listed for Select counties in Tennessee (TN). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H5828-016-000?

The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $6,460. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H5828-016-000?

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 H5828-016-000?

The plan record lists $130 copay.

Does H5828-016-000 report extra benefits?

Yes. CMS reports dental, vision, hearing, over-the-counter allowance, 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 H5828-016-000 fits

Full CMS plan ID
H5828-016-000
Contract
H5828
Base plan code
H5828-016
Segment
000
Carrier
Wellpoint
Plan type
HMOPOS
Service area
Select counties in Tennessee (TN)

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.

  • Bedford, TN
  • Benton, TN
  • Bledsoe, TN
  • Bradley, TN
  • Carroll, TN
  • Carter, TN
  • Chester, TN
  • Claiborne, TN
  • Clay, TN
  • Cocke, TN
  • Coffee, TN
  • Crockett, TN

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

Same CMS contract

H5828-008-000 Wellpoint Extra Help (HMO-POS) Tennessee · HMOPOS H5828-013-000 Wellpoint Medicare Advantage (HMO-POS) Tennessee · HMOPOS H5828-014-000 Wellpoint Medicare Advantage 2 (HMO-POS) Select counties in Tennessee · HMOPOS H5828-015-000 Wellpoint Medicare Advantage 2 (HMO-POS) Select counties in Tennessee · HMOPOS H5828-017-000 Wellpoint Medicare Advantage 2 (HMO-POS) Select counties in Tennessee · HMOPOS H5828-001-000 Wellpoint Full Dual Advantage Support (HMO D-SNP) Tennessee · HMO H5828-002-000 Wellpoint Full Dual Advantage (HMO D-SNP) Tennessee · HMO H5828-018-000 Wellpoint Full Dual Advantage 2 (HMO D-SNP) Select Counties in Tennessee · HMO

About this code

What H5828-016-000 identifies

H5828-016-000 is a Contract Year 2026 Medicare plan segment code. Searches written as H5828-016, H5828 016, or the compact full CMS ID H5828016000 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.