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

2027 Medicare plan code

H8889-021

Medicare Plan

Medica Advantage Preferred (PPO) · Medica · Local PPO · 001

Full CMS plan ID: H8889-021-001

H8889-021-001 is the full CMS identifier for the H8889-021 Medicare plan. Common searches include H8889 021 and H8889021.

2027

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

● CMS 2027 plan record

Medica Advantage Preferred (PPO)

H8889-021-001 001 Local PPO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Per admission $250 per stay
Out-of-network

Tier 1: $315 per stay

Point of service

Not separately reported

02

Emergency transport

Ambulance

Ground · in-network$250 copay
Air · in-network$325 copay
03

Emergency services

Emergency room

$150 copay

Waived if admitted within 1 days

04

Medical maximum

Maximum out-of-pocket

In-network$4,450
Combined in + out$6,700
05

Skilled care at home

Home health

In-network$0 cost share
Out-of-network20% coinsurance
06

Monthly cost

Premium & giveback

Part C premium$105.60 / month
Consolidated C + D$218 / month

CMS reports no Part B premium reduction for this plan.

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-networkPrimary Care Physician Services: $0 cost share
Out-of-network7a: $10 copay

Specialist

In-networkPhysician Specialist Services: $20 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–$95 copay
Out-of-network8a1: $0–$95 copay

Laboratory services

In-networkNot separately reported
Out-of-network8a2: $0 cost share

X-rays & standard imaging

In-networkNot separately reported
Out-of-network8b3: $0 cost share

MRI, CT & PET imaging

In-networkDiagnostic Radiological Services: $0–$95 copay
Out-of-network8b1: $0–$95 copay
Urgent & hospital care6 benefits

Urgent care

In-networkUrgently Needed Services: $30 copay
Out-of-networkNot separately reported

Emergency room

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

Ground ambulance

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

Air ambulance

In-network$325 copay
Out-of-network$325 copay

Outpatient hospital

In-networkOutpatient Hospital Services: $0–$300 copay; Observation Services: $125 copay
Out-of-network9a1: $0–$375 copay; 9a2: $155 copay

Outpatient surgery / ASC

In-networkAmbulatory Surgical Center (ASC) Services: $0–$200 copay
Out-of-network9b: $0–$250 copay
Recovery & therapy5 benefits

Home health

In-network$0 cost share
Out-of-network20% coinsurance

Skilled nursing facility

In-networkSkilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–42; $0 / day for days 43–100
Out-of-networkSkilled nursing facility: Tier 1: $100 / day for days 1–20; $221 / day for days 21–44; $0 / day for days 45–100; $0 per stay

Cardiac & pulmonary rehabilitation

In-networkCardiac Rehabilitation Services: $20 copay; Intensive Cardiac Rehabilitation Services: $20 copay; Pulmonary Rehabilitation Services: $20 copay; SET for PAD Services: $20 copay; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-network3-1: $35 copay; 3-2: $35 copay; 3-3: $35 copay; 3-4: $35 copay

Occupational therapy

In-networkOccupational Therapy Services: $20 copay
Out-of-network7c: $35 copay

Physical & speech therapy

In-networkPhysical Therapy and Speech-Language Pathology Services: $20 copay
Out-of-network7i: $35 copay
Behavioral health2 benefits

Mental health services

In-networkPartial Hospitalization Program: $50 copay; Individual Sessions for Mental Health Specialty Services: $20 copay; Group Sessions for Mental Health Specialty Services: $10 copay; Individual Sessions for Psychiatric Services: $20 copay; Group Sessions for Psychiatric Services: $10 copay; Inpatient psychiatric hospital: Tier 1: $125 per stay
Out-of-network5a: $65 copay; 7e1: $35 copay; 7e2: $25 copay; 7h1: $35 copay; 7h2: $25 copay; Inpatient psychiatric hospital: Tier 1: $155 per stay

Substance use treatment

In-networkIntensive Outpatient Program Services: $50 copay; Individual Sessions for Outpatient Substance Abuse: $20 copay; Group Sessions for Outpatient Substance Abuse: $10 copay
Out-of-network5b: $65 copay; 9c1: $35 copay; 9c2: $25 copay
Specialty care2 benefits

Podiatry

In-networkPodiatry Services: $20 copay; 7f(NMC): Not applicable
Out-of-network7f: $35 copay

Chiropractic

In-networkChiropractic Services: $10 copay
Out-of-network7b: $25 copay
Supplemental benefits7 benefits

Dental

In-networkMedicare Dental Services: $0–$20 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $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, fixed: 50% coinsurance; Oral and Maxillofacial Surgery: 50% coinsurance; Adjunctive General Services: 50% coinsurance
Out-of-network16a: $0–$20 copay; 16b1: 50% coinsurance; 16b2: 50% coinsurance; 16b4: 50% coinsurance; 16b5: 50% coinsurance; 16b6: 50% coinsurance; 16c1: 50% coinsurance; 16c2: 50% coinsurance; 16c3: 50% coinsurance; 16c7: 50% coinsurance; 16c8: 50% coinsurance; 16c10: 50% coinsurance

Vision

In-networkEye Exams: $0–$20 copay; 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: $0 cost share
Out-of-network17a: $0–$35 copay; 17a1: $0 cost share; 17a2: $0 cost share; 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: $0–$20 copay; Prescription Hearing Aids (all types): $549–$1,299 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable; OTC Hearing Aids: $999 copay
Out-of-network18a: $0–$35 copay; 18a1: $0 cost share; 18a2: $0 cost share; 18b1: $549–$1,299 copay; 18c: $999 copay

Transportation

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

Fitness & wellness

In-networkFitness Benefit: $0 cost share
Out-of-network14c4: $0 cost share

Over-the-counter allowance

In-networkOver-the-Counter (OTC) Items: $0 cost share
Out-of-network13b: $0 cost share

Meals

Not applicable
In-networkMeal Benefit: Not applicable
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview

Premium & Part B giveback

$105.60 Part C premium / month · CMS reports no Part B premium reduction for this plan.

Maximum out-of-pocket (MOOP)

In-network$4,450
Combined in + out$6,700

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Annual health deductible

$0

Combined network deductible

Not separately reported

Part D premium

$112.40 / month

Network & referrals

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

Prescription drugs6 tiers

Part D deductible

$280 / year

Drug tier 1

Standard retail: $0 copay · Preferred retail: $0 copay · 30-day supply

Drug tier 2

Standard retail: $10 copay · Preferred retail: $10 copay · 30-day supply

Drug tier 3

Standard retail: 20% coinsurance · Preferred retail: 20% coinsurance · 30-day supply

Drug tier 4

Standard retail: 25% coinsurance · Preferred retail: 25% coinsurance · 30-day supply

Drug tier 5

Standard retail: 30% coinsurance · Preferred retail: 30% coinsurance · 30-day supply

Drug tier 6

Standard retail: $0 copay · Preferred retail: $0 copay · 30-day supply

Using this plan

Understand H8889-021-001

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

Medica Advantage Preferred (PPO) is a 2027 Local PPO offered by Medica in 001. 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: $20 copay
Laboratory services
Not separately reported

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
Diagnostic Procedures/Tests: $0–$95 copay
MRI, CT & PET imaging
Diagnostic Radiological Services: $0–$95 copay
Outpatient hospital
Outpatient Hospital Services: $0–$300 copay; Observation Services: $125 copay

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

Emergency & hospital care

Emergency room
$150 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 no Part B premium reduction for this plan.

Availability

Who can enroll

Service area
001 (MN)
Plan type
Local PPO
Contract / plan
H8889-021
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: $0–$20 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $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, fixed: 50% coinsurance; Oral and Maxillofacial Surgery: 50% coinsurance; Adjunctive General Services: 50% coinsurance
VisionEye Exams: $0–$20 copay; 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: $0 cost share
HearingHearing Exams: $0–$20 copay; Prescription Hearing Aids (all types): $549–$1,299 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable; OTC Hearing Aids: $999 copay
Over-the-counter allowanceOver-the-Counter (OTC) Items: $0 cost share
Fitness & wellnessFitness Benefit: $0 cost share

Plan-specific answers

Frequently asked questions

Where is H8889-021-001 available?

Medica Advantage Preferred (PPO) is listed for 001 (MN). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H8889-021-001?

The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $4,450. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H8889-021-001?

The listed consolidated Part C and Part D premium is $218 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H8889-021-001?

The plan record lists $150 copay, waived when an admission meets the plan's stated timing rule.

Does H8889-021-001 report extra benefits?

Yes. CMS reports dental, vision, hearing, over-the-counter allowance, 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.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H8889-021-001 fits

Full CMS plan ID
H8889-021-001
Contract
H8889
Base plan code
H8889-021
Segment
001
Carrier
Medica
Plan type
Local PPO
Service area
001 (MN)

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.

  • Anoka, MN
  • Carver, MN
  • Dakota, MN
  • Ramsey, MN
  • Scott, MN
  • Washington, MN

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 6 county links

Same CMS contract

H8889-021-002 Medica Advantage Preferred (PPO) 002 · Local PPO H8889-002-000 Medica Advantage Select (PPO) Select counties in MN - North · Local PPO H8889-009-000 Medica Advantage Salute (PPO) Select counties in MN, NE, ND and SD · Local PPO H8889-019-001 Medica Advantage Value (PPO) 001 · Local PPO H8889-019-002 Medica Advantage Value (PPO) 002 · Local PPO H8889-020-001 Medica Advantage Select (PPO) 001 · Local PPO H8889-020-002 Medica Advantage Select (PPO) 002 · Local PPO H8889-022-000 Medica Advantage Essential (PPO) Select counties in MN - North · Local PPO

About this code

What H8889-021-001 identifies

H8889-021-001 is a Contract Year 2027 Medicare plan segment code. Searches written as H8889-021, H8889 021, or the compact full CMS ID H8889021001 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.