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

2026 Medicare plan code

H8889-017

Medicare Plan

Medica Advantage Value (PPO) · Medica · Local PPO · Select counties in SD

Full CMS plan ID: H8889-017-000

H8889-017-000 is the full CMS identifier for the H8889-017 Medicare plan. Common searches include H8889 017 and H8889017.

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

Medica Advantage Value (PPO)

H8889-017-000 Select counties in SD Local PPO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–5 $500 / day
Days 6–90 $0 / day
Total of listed copays · 5 charged days $2,500
02

Emergency transport

Ambulance

Ground · in-network$370 copay
Air · in-network$475 copay
03

Emergency services

Emergency room

$130 copay

Waived if admitted

04

Medical maximum

Maximum out-of-pocket

In-network$6,750
Combined in + out$6,750
05

Skilled care at home

Home health

In-networkCost share not reported
Out-of-network30% coinsurance
06

Monthly cost

Premium & giveback

Part C premium$25 / month
Consolidated C + D$25 / month

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-networkCost share not reported
Out-of-network$25 copay

Specialist

In-network$60 copay
Out-of-network$70 copay

Preventive care

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

Diagnostic procedures & tests

In-network$0–$125 copay
Out-of-network$0–$125 copay

Laboratory services

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

X-rays & standard imaging

In-network$0–$250 copay
Out-of-network$0–$250 copay

MRI, CT & PET imaging

In-network$85 copay
Out-of-network$85 copay
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$370 copay
Out-of-network$370 copay

Air ambulance

In-network$475 copay
Out-of-network$475 copay

Outpatient hospital

In-network$0–$550 copay
Out-of-network$0–$600 copay

Outpatient surgery / ASC

In-network$0–$450 copay
Out-of-network$0–$500 copay
Recovery & therapy5 benefits

Home health

In-networkCost share not reported
Out-of-network30% coinsurance

Skilled nursing facility

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

Cardiac & pulmonary rehabilitation

In-network$40 copay
Out-of-network$60 copay

Occupational therapy

In-network$50 copay
Out-of-network$60 copay

Physical & speech therapy

In-network$60 copay
Out-of-network$70 copay
Behavioral health2 benefits

Mental health services

In-network$140 copay
Out-of-network$150 copay

Substance use treatment

In-network$140 copay
Out-of-network$150 copay
Specialty care2 benefits

Podiatry

In-network$60 copay
Out-of-network$70 copay

Chiropractic

In-network$15 copay
Out-of-network$35 copay
Supplemental benefits7 benefits

Dental

In-network$0–$60 copay
Out-of-network$0–$60 copay

Vision

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

Hearing

In-network$549–$1,299 copay
Out-of-network$549–$1,299 copay

Transportation

Not reported in this CMS export

Not reported in this CMS export

Fitness & wellness

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

Over-the-counter allowance

Not reported in this CMS export

Not reported in this CMS export

Meals

In-networkCost share not reported
Out-of-networkCost share not reported
Plan costs & rulesCoverage overview

Premium & Part B giveback

$25 Part C premium / month · Part B giveback not separately reported

Maximum out-of-pocket (MOOP)

In-network$6,750
Combined in + out$6,750

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Network & referrals

Local PPO · Referrals: Not required · Out-of-network coverage: Yes

Prescription drugs5 tiers

Part D deductible

Not reported

Drug tier 1

$0 retail copay · 30-day supply

Drug tier 2

$5 retail copay · 30-day supply

Drug tier 3

18% retail coinsurance · 30-day supply

Drug tier 4

50% retail coinsurance · 30-day supply

Drug tier 5

25% retail coinsurance · 30-day supply

Using this plan

Understand H8889-017-000

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

Medica Advantage Value (PPO) is a 2026 Local PPO offered by Medica in Select counties in SD. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $2,500 across 5 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
Cost share not reported
Specialist
$60 copay
Laboratory services
Cost share not reported

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
$0–$125 copay
MRI, CT & PET imaging
$85 copay
Outpatient hospital
$0–$550 copay

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

Emergency & hospital care

Emergency room
$130 copay
Listed inpatient stages
$2,500 total

5 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 SD (SD)
Plan type
Local PPO
Contract / plan
H8889-017
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–$60 copay
VisionCost share not reported
Hearing$549–$1,299 copay
Fitness & wellnessCost share not reported
MealsCost share not reported

Plan-specific answers

Frequently asked questions

Where is H8889-017-000 available?

Medica Advantage Value (PPO) is listed for Select counties in SD (SD). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H8889-017-000?

The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $6,750. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H8889-017-000?

The listed consolidated Part C and Part D premium is $25 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H8889-017-000?

The plan record lists $130 copay, waived when an admission meets the plan's stated timing rule.

Does H8889-017-000 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 H8889-017-000 fits

Full CMS plan ID
H8889-017-000
Contract
H8889
Base plan code
H8889-017
Segment
000
Carrier
Medica
Plan type
Local PPO
Service area
Select counties in SD (SD)

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.

  • Brookings, SD
  • Butte, SD
  • Clark, SD
  • Codington, SD
  • Custer, SD
  • Davison, SD
  • Day, SD
  • Deuel, SD
  • Fall River, SD
  • Hamlin, SD
  • Kingsbury, SD
  • Lawrence, SD

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

Same CMS contract

H8889-009-000 Medica Advantage Solution H8889-009 (PPO) Select counties in IA, MN, NE, ND and SD · Local PPO H8889-013-000 Medica Advantage Preferred (PPO) Select counties in ND and SD · Local PPO H8889-018-000 Medica Advantage Select (PPO) Select counties in SD · Local PPO H8889-801-000 Medica Group Advantage Solution (PPO) Select Counties in the US · Local PPO H8889-001-000 Medica Advantage Solution H8889-001 (PPO) Minneapolis/St. Paul Metro Area · Local PPO H8889-002-000 Medica Advantage Solution H8889-002 (PPO) Select Counties in MN · Local PPO H8889-003-000 Medica Advantage Solution H8889-003 (PPO) Minneapolis/St. Paul Metro Area · Local PPO H8889-004-000 Medica Advantage Solution H8889-004 (PPO) Southern Minnesota · Local PPO

About this code

What H8889-017-000 identifies

H8889-017-000 is a Contract Year 2026 Medicare plan segment code. Searches written as H8889-017, H8889 017, or the compact full CMS ID H8889017000 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.