In-network
Inpatient hospital
Per admission $200 per stay
Plan-listed inpatient copay $200
● CMS 2026 plan record
UCLA Health Medicare Advantage Principal Plan (HMO)
Emergency transport
Ambulance
Ground · in-network$200 copay
Air · in-network20% coinsurance
Emergency services
Emergency room
$150 copay
Waived if admitted within 36 hours
Medical maximum
Maximum out-of-pocket
In-network$2,499
Combined in + outNot reported
Skilled care at home
Home health
In-networkNo cost share reported
Out-of-networkNot separately reported
Monthly cost
Premium & giveback
Part C premium$0 / month
Consolidated C + D$0 / month
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. Quick-reference values should be confirmed in current official plan documents.
About this code
What H4647-001-000 identifies
H4647-001-000 is a Contract Year 2026 Medicare plan segment code. The compact form H4647001000 refers to the same normalized contract, plan, and segment shown on this page.
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.