Medicare Plan Lookup Official CMS data · Contract Year 2027
CMS 2027 data

2027 Medicare plan code

H3916-012

Medicare Plan

Freedom Blue PPO Basic (PPO) · Highmark Blue Cross Blue Shield or Highmark Blue Shield · Local PPO · Central and Northeastern PA

Full CMS plan ID: H3916-012-000

H3916-012-000 is the full CMS identifier for the H3916-012 Medicare plan. Common searches include H3916 012 and H3916012.

2027

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2027 plan record

Freedom Blue PPO Basic (PPO)

H3916-012-000 Central and Northeastern PA Local PPO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Per admission $340 per stay
Out-of-network

Tier 1: $340 per stay

Point of service

Not separately reported

02

Emergency transport

Ambulance

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

Emergency services

Emergency room

$130 copay

Waived if admitted within 3 days

04

Medical maximum

Maximum out-of-pocket

In-network$5,900
Combined in + out$8,950
05

Skilled care at home

Home health

In-network$0 cost share
Out-of-network30% coinsurance
06

Monthly cost

Premium & giveback

Part C premium$5 / month
Consolidated C + DNot reported

CMS reports a Part B premium reduction of $19 per month.

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-networkPrimary Care Physician Services: $0 cost share
Out-of-network7a: $0 cost share

Specialist

In-networkPhysician Specialist Services: $35 copay
Out-of-network7d: $35 copay

Preventive care

In-networkAnnual Physical Exam: $0 cost share; Kidney Disease Education Services: $0 cost share; 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-network14b: $0 cost share; 14d: $0 cost share; 14e1: $0 cost share; 14e2: $0 cost share; 14e4: $0 cost share; 14e5: $0 cost share; 14a: $0 cost share
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-networkDiagnostic Procedures/Tests: $0–$20 copay
Out-of-network8a1: $20 copay

Laboratory services

In-networkLab Services: $0–$20 copay
Out-of-network8a2: $20 copay

X-rays & standard imaging

In-networkOutpatient X-Ray Services: $25 copay
Out-of-network8b3: $25 copay

MRI, CT & PET imaging

In-networkDiagnostic Radiological Services: $150 copay
Out-of-network8b1: $150 copay
Urgent & hospital care6 benefits

Urgent care

In-networkUrgently Needed Services: $45 copay
Out-of-networkNot separately reported

Emergency room

In-network$130 copay
Out-of-networkNot separately reported

Ground ambulance

In-network$300 copay
Out-of-network$300 copay + 30% coinsurance

Air ambulance

In-network$300 copay
Out-of-network$300 copay + 30% coinsurance

Outpatient hospital

In-networkOutpatient Hospital Services: $0–$200 copay; Observation Services: $200 copay
Out-of-network9a1: $200 copay; 9a2: $200 copay

Outpatient surgery / ASC

In-networkAmbulatory Surgical Center (ASC) Services: $0–$100 copay
Out-of-network9b: $100 copay
Recovery & therapy5 benefits

Home health

In-network$0 cost share
Out-of-network30% coinsurance

Skilled nursing facility

In-networkSkilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–100
Out-of-networkSkilled nursing facility: Tier 1: 30% coinsurance

Cardiac & pulmonary rehabilitation

In-networkCardiac Rehabilitation Services: $0 cost share; Intensive Cardiac Rehabilitation Services: $0 cost share; Pulmonary Rehabilitation Services: $0 cost share; SET for PAD Services: $0 cost share; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-network3-1: 30% coinsurance; 3-2: 30% coinsurance; 3-3: 30% coinsurance; 3-4: 30% coinsurance

Occupational therapy

In-networkOccupational Therapy Services: $35 copay
Out-of-network7c: $35 copay

Physical & speech therapy

In-networkPhysical Therapy and Speech-Language Pathology Services: $35 copay
Out-of-network7i: $35 copay
Behavioral health2 benefits

Mental health services

In-networkPartial Hospitalization Program: $0 cost share; Individual Sessions for Mental Health Specialty Services: $35 copay; Group Sessions for Mental Health Specialty Services: $35 copay; Individual Sessions for Psychiatric Services: $35 copay; Group Sessions for Psychiatric Services: $35 copay; Inpatient psychiatric hospital: Tier 1: $340 per stay
Out-of-network5a: 30% coinsurance; 7e1: $35 copay; 7e2: $35 copay; 7h1: $35 copay; 7h2: $35 copay; Inpatient psychiatric hospital: Tier 1: $340 per stay

Substance use treatment

In-networkIntensive Outpatient Program Services: $0 cost share; Individual Sessions for Outpatient Substance Abuse: $35 copay; Group Sessions for Outpatient Substance Abuse: $35 copay
Out-of-network5b: 30% coinsurance; 9c1: $35 copay; 9c2: $35 copay
Specialty care2 benefits

Podiatry

In-networkPodiatry Services: $35 copay; 7f(NMC): $35 copay
Out-of-network7f: $35 copay; 7f_2: $35 copay

Chiropractic

In-networkChiropractic Services: $15 copay
Out-of-network7b: $15 copay
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; Prophylaxis (Cleaning): $0 cost share
Out-of-network16a: $35 copay; 16b1: 30% coinsurance; 16b2: 30% coinsurance; 16b4: 30% coinsurance

Vision

In-networkEye Exams: $0–$35 copay; Other Eye Exam Services: Not applicable; Eyeglasses (lenses and frames): $0–$40 copay; Eyeglass frames: $0–$40 copay
Out-of-network17a: $35 copay; 17a1: $50 copay; 17b: $0 cost share; 17b1: $0 cost share; 17b2: $0 cost share; 17b3: $0 cost share; 17b4: $0 cost share; 17b5: $0 cost share

Hearing

In-networkHearing Exams: $35 copay; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): $599–$899 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-network18a: $35 copay; 18a1: $35 copay; 18b1: $0 cost share

Transportation

Not applicable
In-network10b(NMC): Not applicable
Out-of-networkNot separately reported

Fitness & wellness

In-networkNot separately reported
Out-of-network14c4: 50% coinsurance

Over-the-counter allowance

Not applicable
In-networkOver-the-Counter (OTC) Items: Not applicable
Out-of-networkNot separately reported

Meals

In-networkMeal Benefit: $0 cost share
Out-of-network13c: $0 cost share
Plan costs & rulesCoverage overview

Premium & Part B giveback

$5 Part C premium / month · CMS reports a Part B premium reduction of $19 per month.

Maximum out-of-pocket (MOOP)

In-network$5,900
Combined in + out$8,950

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Annual health deductible

$0

Combined network deductible

Not separately reported

Part D premium

Not reported

Network & referrals

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

Prescription drugs0 tiers

Part D deductible

Not reported

Using this plan

Understand H3916-012-000

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

Freedom Blue PPO Basic (PPO) is a 2027 Local PPO offered by Highmark Blue Cross Blue Shield or Highmark Blue Shield in Central and Northeastern PA. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals.

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: $35 copay
Laboratory services
Lab Services: $0–$20 copay

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
Diagnostic Procedures/Tests: $0–$20 copay
MRI, CT & PET imaging
Diagnostic Radiological Services: $150 copay
Outpatient hospital
Outpatient Hospital Services: $0–$200 copay; Observation Services: $200 copay

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

Emergency & hospital care

Emergency room
$130 copay

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 $19 per month.

Availability

Who can enroll

Service area
Central and Northeastern PA (PA)
Plan type
Local PPO
Contract / plan
H3916-012
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; Prophylaxis (Cleaning): $0 cost share
VisionEye Exams: $0–$35 copay; Other Eye Exam Services: Not applicable; Eyeglasses (lenses and frames): $0–$40 copay; Eyeglass frames: $0–$40 copay
HearingHearing Exams: $35 copay; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): $599–$899 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Fitness & wellnessNot separately reported
MealsMeal Benefit: $0 cost share

Plan-specific answers

Frequently asked questions

Where is H3916-012-000 available?

Freedom Blue PPO Basic (PPO) is listed for Central and Northeastern PA (PA). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H3916-012-000?

The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $5,900. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H3916-012-000?

The listed Part C premium is $5 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H3916-012-000?

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

Does H3916-012-000 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 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.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H3916-012-000 fits

Full CMS plan ID
H3916-012-000
Contract
H3916
Base plan code
H3916-012
Segment
000
Carrier
Highmark Blue Cross Blue Shield or Highmark Blue Shield
Plan type
Local PPO
Service area
Central and Northeastern PA (PA)

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.

  • Adams, PA
  • Berks, PA
  • Bradford, PA
  • Carbon, PA
  • Centre, PA
  • Clinton, PA
  • Columbia, PA
  • Cumberland, PA
  • Dauphin, PA
  • Franklin, PA
  • Fulton, PA
  • Juniata, PA

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

Exact county navigation

These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.

Show 34 county links
Pennsylvania

Same CMS contract

H3916-001-000 Freedom Blue PPO Classic (PPO) Southwestern PA · Local PPO H3916-002-000 Freedom Blue PPO Classic (PPO) West Central PA · Local PPO H3916-005-000 Freedom Blue PPO Deluxe (PPO) Central and Northeastern PA · Local PPO H3916-015-000 Freedom Blue PPO Standard (PPO) Central and Northeastern PA · Local PPO H3916-018-000 Freedom Blue PPO ValueRx (PPO) Central and Northeastern PA · Local PPO H3916-022-000 Freedom Blue PPO Select (PPO) Southwestern PA · Local PPO H3916-024-000 Freedom Blue PPO Select (PPO) West Central PA · Local PPO H3916-032-000 Freedom Blue PPO ValueRx (PPO) Southwestern PA · Local PPO

About this code

What H3916-012-000 identifies

H3916-012-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H3916-012, H3916 012, or the compact full CMS ID H3916012000 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.