In-network
Inpatient hospital
Days 1–5 $550 / day
Days 6–90 $0 / day
Total of listed copays · 5 charged days $2,750
Out-of-network
Not separately reported
Point of service
Tier 1: 50% coinsurance
● CMS 2027 plan record
PacificSource Medicare Idaho Basic (HMO-POS)
Choose and order benefitsSelections are saved only on this device.
Emergency transport
Ambulance
Ground · in-network$400 copay
Air · in-network$400 copay
Emergency services
Emergency room
$130 copay
Waived if admitted within 72 hours
Medical maximum
Maximum out-of-pocket
In-network$7,150
Combined in + outNo combined out-of-pocket maximum
Skilled care at home
Home health
In-network$0 cost share
Out-of-networkNot separately reported
Monthly cost
Premium & giveback
Part C premium$0 / month
Consolidated C + DNot reported
CMS reports a Part B premium reduction of $60 per month.
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Primary care physician
In: Primary Care Physician Services: $0 cost share · Out: Not separately reported
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Specialist
In: Physician Specialist Services: $0–$45 copay · Out: Not separately reported
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Preventive care
In: Annual Physical Exam: $0 cost share; Kidney Disease Education Services: 20% coinsurance; Glaucoma Screening: $0 cost share; Diabetes Self-Management Training: $0 cost share; Digital Rectal Exams: $0 cost share; EKG following Welcome Visit: $0 cost share · Out: Not separately reported
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Diagnostic procedures & tests
In: Diagnostic Procedures/Tests: 20% coinsurance + $15 copay · Out: Not separately reported
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Laboratory services
In: Lab Services: 20% coinsurance + $0 copay · Out: Not separately reported
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X-rays & standard imaging
In: Outpatient X-Ray Services: $0–$15 copay · Out: Not separately reported
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MRI, CT & PET imaging
In: Diagnostic Radiological Services: 20% coinsurance + $0 copay · Out: Not separately reported
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Urgent care
In: Urgently Needed Services: $50 copay · Out: Not separately reported
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Emergency room
In: $130 copay · Out: Not separately reported
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Ground ambulance
In: $400 copay · Out: Not separately reported
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Air ambulance
In: $400 copay · Out: Not separately reported
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Outpatient hospital
In: Outpatient Hospital Services: $0–$425 copay; Observation Services: $425 copay · Out: Not separately reported
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Outpatient surgery / ASC
In: Ambulatory Surgical Center (ASC) Services: $0–$350 copay · Out: Not separately reported
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Home health
In: $0 cost share · Out: Not separately reported
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Skilled nursing facility
In: Skilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–100 · Out: Not separately reported
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Cardiac & pulmonary rehabilitation
In: Cardiac Rehabilitation Services: $35 copay; Intensive Cardiac Rehabilitation Services: $35 copay; Pulmonary Rehabilitation Services: $15 copay; SET for PAD Services: $25 copay; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable · Out: Not separately reported
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Occupational therapy
In: Occupational Therapy Services: $20 copay · Out: Not separately reported
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Physical & speech therapy
In: Physical Therapy and Speech-Language Pathology Services: $25 copay · Out: Not separately reported
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Mental health services
In: Partial Hospitalization Program: $40 copay; Individual Sessions for Mental Health Specialty Services: $25 copay; Group Sessions for Mental Health Specialty Services: $25 copay; Individual Sessions for Psychiatric Services: $25 copay; Group Sessions for Psychiatric Services: $25 copay; Inpatient psychiatric hospital: Tier 1: $550 / day for days 1–4; $0 / day for days 5–90 · Out: Not separately reported
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Substance use treatment
In: Intensive Outpatient Program Services: $40 copay; Individual Sessions for Outpatient Substance Abuse: $0 cost share; Group Sessions for Outpatient Substance Abuse: $0 cost share · Out: Not separately reported
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Podiatry
In: Podiatry Services: $45 copay; 7f(NMC): Not applicable · Out: Not separately reported
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Chiropractic
In: Chiropractic Services: $15 copay · Out: Not separately reported
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Dental
In: Medicare Dental Services: $35 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Other Diagnostic Dental Services: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Other Preventive Dental Services: $0 cost share; Restorative Services: 50% coinsurance; Endodontics: 50% coinsurance; Periodontics: 50% coinsurance; Prosthodontics, removable: 50% coinsurance; Prosthodontics, fixed: 50% coinsurance; Oral and Maxillofacial Surgery: 50% coinsurance; Adjunctive General Services: 50% coinsurance · Out: Not separately reported
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Vision
In: Eye Exams: $0 cost share; Routine Eye Exams: $0 cost share; Other Eye Exam Services: $0 cost share; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: Not applicable · Out: Not separately reported
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Hearing
In: Hearing Exams: $20 copay; Prescription Hearing Aids (all types): $599–$999 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable · Out: Not separately reported
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Transportation
In: 10b(NMC): Not applicable · Out: Not separately reported
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Fitness & wellness
In: Fitness Benefit: $0 cost share · Out: Not separately reported
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Over-the-counter allowance
In: Over-the-Counter (OTC) Items: Not applicable · Out: Not separately reported
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Meals
In: Meal Benefit: Not applicable · Out: Not separately reported
Plan details
All plan benefits
No benefits match that search.
Medical care3 benefits
Primary care physician
In-networkPrimary Care Physician Services: $0 cost share
Out-of-networkNot separately reported
Specialist
In-networkPhysician Specialist Services: $0–$45 copay
Out-of-networkNot separately reported
Preventive care
In-networkAnnual Physical Exam: $0 cost share; Kidney Disease Education Services: 20% coinsurance; Glaucoma Screening: $0 cost share; Diabetes Self-Management Training: $0 cost share; Digital Rectal Exams: $0 cost share; EKG following Welcome Visit: $0 cost share
Out-of-networkNot separately reported
Diagnostics & imaging4 benefits
Diagnostic procedures & tests
In-networkDiagnostic Procedures/Tests: 20% coinsurance + $15 copay
Out-of-networkNot separately reported
Laboratory services
In-networkLab Services: 20% coinsurance + $0 copay
Out-of-networkNot separately reported
X-rays & standard imaging
In-networkOutpatient X-Ray Services: $0–$15 copay
Out-of-networkNot separately reported
MRI, CT & PET imaging
In-networkDiagnostic Radiological Services: 20% coinsurance + $0 copay
Out-of-networkNot separately reported
Urgent & hospital care6 benefits
Urgent care
In-networkUrgently Needed Services: $50 copay
Out-of-networkNot separately reported
Emergency room
In-network$130 copay
Out-of-networkNot separately reported
Ground ambulance
In-network$400 copay
Out-of-networkNot separately reported
Air ambulance
In-network$400 copay
Out-of-networkNot separately reported
Outpatient hospital
In-networkOutpatient Hospital Services: $0–$425 copay; Observation Services: $425 copay
Out-of-networkNot separately reported
Outpatient surgery / ASC
In-networkAmbulatory Surgical Center (ASC) Services: $0–$350 copay
Out-of-networkNot separately reported
Recovery & therapy5 benefits
Home health
In-network$0 cost share
Out-of-networkNot separately reported
Skilled nursing facility
In-networkSkilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–100
Out-of-networkNot separately reported
Point of serviceSkilled nursing facility: Tier 1: 50% coinsurance
Cardiac & pulmonary rehabilitation
In-networkCardiac Rehabilitation Services: $35 copay; Intensive Cardiac Rehabilitation Services: $35 copay; Pulmonary Rehabilitation Services: $15 copay; SET for PAD Services: $25 copay; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-networkNot separately reported
Occupational therapy
In-networkOccupational Therapy Services: $20 copay
Out-of-networkNot separately reported
Physical & speech therapy
In-networkPhysical Therapy and Speech-Language Pathology Services: $25 copay
Out-of-networkNot separately reported
Behavioral health2 benefits
Mental health services
In-networkPartial Hospitalization Program: $40 copay; Individual Sessions for Mental Health Specialty Services: $25 copay; Group Sessions for Mental Health Specialty Services: $25 copay; Individual Sessions for Psychiatric Services: $25 copay; Group Sessions for Psychiatric Services: $25 copay; Inpatient psychiatric hospital: Tier 1: $550 / day for days 1–4; $0 / day for days 5–90
Out-of-networkNot separately reported
Point of serviceInpatient psychiatric hospital: Tier 1: 50% coinsurance
Substance use treatment
In-networkIntensive Outpatient Program Services: $40 copay; Individual Sessions for Outpatient Substance Abuse: $0 cost share; Group Sessions for Outpatient Substance Abuse: $0 cost share
Out-of-networkNot separately reported
Specialty care2 benefits
Podiatry
In-networkPodiatry Services: $45 copay; 7f(NMC): Not applicable
Out-of-networkNot separately reported
Chiropractic
In-networkChiropractic Services: $15 copay
Out-of-networkNot separately reported
Supplemental benefits7 benefits
Dental
In-networkMedicare Dental Services: $35 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Other Diagnostic Dental Services: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Other Preventive Dental Services: $0 cost share; Restorative Services: 50% coinsurance; Endodontics: 50% coinsurance; Periodontics: 50% coinsurance; Prosthodontics, removable: 50% coinsurance; Prosthodontics, fixed: 50% coinsurance; Oral and Maxillofacial Surgery: 50% coinsurance; Adjunctive General Services: 50% coinsurance
Out-of-networkNot separately reported
Vision
In-networkEye Exams: $0 cost share; Routine Eye Exams: $0 cost share; Other Eye Exam Services: $0 cost share; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: Not applicable
Out-of-networkNot separately reported
Hearing
In-networkHearing Exams: $20 copay; Prescription Hearing Aids (all types): $599–$999 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Out-of-networkNot separately reported
Transportation
Not applicableIn-network10b(NMC): Not applicable
Out-of-networkNot separately reported
Fitness & wellness
In-networkFitness Benefit: $0 cost share
Out-of-networkNot separately reported
Over-the-counter allowance
Not applicableIn-networkOver-the-Counter (OTC) Items: Not applicable
Out-of-networkNot separately reported
Meals
Not applicableIn-networkMeal Benefit: Not applicable
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview
Premium & Part B giveback
$0 Part C premium / month · CMS reports a Part B premium reduction of $60 per month.
Maximum out-of-pocket (MOOP)
In-network$7,150
Combined in + outNo combined out-of-pocket maximum
Medical deductibles
In-network$0
Out-of-network$0
Annual health deductible
Not separately reported
Combined network deductible
$0
Part D premium
Not reported
Network & referrals
HMOPOS · Referrals: Not required · Out-of-network coverage: Not reported
Prescription drugs0 tiers
Part D deductible
Not reported
Using this plan
Understand H3864-050-000
Plain-language context built from this plan’s 2027 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 Idaho Basic (HMO-POS) is a 2027 HMOPOS offered by PacificSource Medicare in Select Idaho Counties. The plan record does not require referrals. Its listed inpatient copay stages total $2,750 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
- Primary Care Physician Services: $0 cost share
- Specialist
- Physician Specialist Services: $0–$45 copay
- Laboratory services
- Lab Services: 20% coinsurance + $0 copay
Separate visits or services; costs are not added together.
Tests & outpatient care
- Diagnostic procedures & tests
- Diagnostic Procedures/Tests: 20% coinsurance + $15 copay
- MRI, CT & PET imaging
- Diagnostic Radiological Services: 20% coinsurance + $0 copay
- Outpatient hospital
- Outpatient Hospital Services: $0–$425 copay; Observation Services: $425 copay
The service setting and billing details can change what you pay.
Emergency & hospital care
- Emergency room
- $130 copay
- Listed inpatient stages
- $2,750 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.
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: CMS reports a Part B premium reduction of $60 per month.
Availability
Who can enroll
- Service area
- Select Idaho Counties (ID)
- Plan type
- HMOPOS
- Contract / plan
- H3864-050
- Coverage year
- 2027
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.
DentalMedicare Dental Services: $35 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Other Diagnostic Dental Services: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Other Preventive Dental Services: $0 cost share; Restorative Services: 50% coinsurance; Endodontics: 50% coinsurance; Periodontics: 50% coinsurance; Prosthodontics, removable: 50% coinsurance; Prosthodontics, fixed: 50% coinsurance; Oral and Maxillofacial Surgery: 50% coinsurance; Adjunctive General Services: 50% coinsurance
VisionEye Exams: $0 cost share; Routine Eye Exams: $0 cost share; Other Eye Exam Services: $0 cost share; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: Not applicable
HearingHearing Exams: $20 copay; Prescription Hearing Aids (all types): $599–$999 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Fitness & wellnessFitness Benefit: $0 cost share
Plan-specific answers
Frequently asked questions
Where is H3864-050-000 available?
PacificSource Medicare Idaho Basic (HMO-POS) is listed for Select Idaho Counties (ID). Enrollment generally requires Medicare eligibility and residence in the plan's service area.
What is the in-network maximum out-of-pocket limit for H3864-050-000?
The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $7,150. Prescription drug spending generally does not count toward this medical limit.
What is the monthly plan premium for H3864-050-000?
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 H3864-050-000?
The plan record lists $130 copay, waived when an admission meets the plan's stated timing rule.
Does H3864-050-000 report extra benefits?
Yes. CMS reports dental, vision, hearing, fitness & wellness. See the detailed benefit rows and official plan documents for limits and conditions.
Source trail
Official CMS, Contract Year 2027
Plan identity and benefits come from CMS PBP data. Benefits and drug cost sharing come from the approved annual PBP tabular extract and its CMS dictionary. Premiums and drug deductibles are cross-checked with the annual Landscape. Geography comes from annual PlanArea and PlanRegionArea records, including exact segments and partial-county or employer/group qualifiers. Quick-reference values should be confirmed in current official plan documents.
Plan context
Where H3864-050-000 fits
- Full CMS plan ID
H3864-050-000- Contract
H3864- Base plan code
H3864-050- Segment
000- Carrier
- PacificSource Medicare
- Plan type
- HMOPOS
- Service area
- Select Idaho Counties (ID)
County/service-area foundation
CMS service-area entries
Service areas come from the annual CMS PlanArea and PlanRegionArea tables for this exact contract, plan, and segment. Partial-county and employer/group qualifiers remain part of the coverage area. Regional PPO county entries use the matching annual Landscape expansion of the CMS region.
- Ada, ID
- Canyon, ID
- Elmore, ID
- Gooding, ID
- Jerome, ID
- Payette, ID
- Twin Falls, ID
- Valley, ID
Exact county navigation
Counties with exact segment geography
These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.
About this code
What H3864-050-000 identifies
H3864-050-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H3864-050, H3864 050, or the compact full CMS ID H3864050000 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.