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

2027 Medicare plan code

H9207-015

Medicare Plan

Jefferson Health Plans Giveback (HMO) · Jefferson Health Plans · HMO · Southeastern PA

Full CMS plan ID: H9207-015-000

H9207-015-000 is the full CMS identifier for the H9207-015 Medicare plan. Common searches include H9207 015 and H9207015.

2027

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

● CMS 2027 plan record

Jefferson Health Plans Giveback (HMO)

H9207-015-000 Southeastern PA HMO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–5 $450 / day
Days 6–90 $0 / day
Total of listed copays · 5 charged days $2,250
Out-of-network

Not separately reported

Point of service

Not separately reported

02

Emergency transport

Ambulance

Ground · in-network$305 copay
Air · in-network20% coinsurance
03

Emergency services

Emergency room

$100 copay

Waived if admitted within 24 hours

04

Medical maximum

Maximum out-of-pocket

In-network$9,850
Combined in + outNot reported
05

Skilled care at home

Home health

In-network$0 cost share
Out-of-networkNot separately reported
06

Monthly cost

Premium & giveback

Part C premium$0 / month
Consolidated C + D$0 / month

CMS reports a Part B premium reduction of $132 per month.

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-networkPrimary Care Physician Services: $0 cost share
Out-of-networkNot separately reported

Specialist

In-networkPhysician Specialist Services: $50 copay
Out-of-networkNot separately reported

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-networkNot separately reported
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-networkDiagnostic Procedures/Tests: $25 copay
Out-of-networkNot separately reported

Laboratory services

Not reported in this CMS export
In-networkNot separately reported
Out-of-networkNot separately reported

X-rays & standard imaging

In-networkOutpatient X-Ray Services: $40 copay
Out-of-networkNot separately reported

MRI, CT & PET imaging

In-networkDiagnostic Radiological Services: $450 copay
Out-of-networkNot separately reported
Urgent & hospital care6 benefits

Urgent care

In-networkUrgently Needed Services: $15 copay
Out-of-networkNot separately reported

Emergency room

In-network$100 copay
Out-of-networkNot separately reported

Ground ambulance

In-network$305 copay
Out-of-networkNot separately reported

Air ambulance

In-network20% coinsurance
Out-of-networkNot separately reported

Outpatient hospital

In-networkOutpatient Hospital Services: $450 copay; Observation Services: $450 copay
Out-of-networkNot separately reported

Outpatient surgery / ASC

In-networkAmbulatory Surgical Center (ASC) Services: $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; $190 / day for days 21–100
Out-of-networkNot separately reported

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-networkNot separately reported

Occupational therapy

In-networkOccupational Therapy Services: $35 copay
Out-of-networkNot separately reported

Physical & speech therapy

In-networkPhysical Therapy and Speech-Language Pathology Services: $50 copay
Out-of-networkNot separately reported
Behavioral health2 benefits

Mental health services

In-networkPartial Hospitalization Program: $55 copay; Individual Sessions for Mental Health Specialty Services: $50 copay; Group Sessions for Mental Health Specialty Services: $50 copay; Individual Sessions for Psychiatric Services: $50 copay; Group Sessions for Psychiatric Services: $50 copay; Inpatient psychiatric hospital: Tier 1: $415 / day for days 1–5; $0 / day for days 6–90
Out-of-networkNot separately reported

Substance use treatment

In-networkIntensive Outpatient Program Services: $55 copay; Individual Sessions for Outpatient Substance Abuse: $40 copay; Group Sessions for Outpatient Substance Abuse: $40 copay
Out-of-networkNot separately reported
Specialty care2 benefits

Podiatry

In-networkPodiatry Services: $40 copay; 7f(NMC): $40 copay
Out-of-networkNot separately reported

Chiropractic

In-networkChiropractic Services: $15 copay
Out-of-networkNot separately reported
Supplemental benefits7 benefits

Dental

In-networkMedicare Dental Services: $40 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; Other Preventive Dental Services: $0 cost share; Restorative Services: $0 cost share; Endodontics: $0 cost share; Periodontics: $0 cost share; Prosthodontics, removable: $0 cost share; Maxillofacial Prosthetics: $0 cost share; Prosthodontics, fixed: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share
Out-of-networkNot separately reported

Vision

In-networkEye Exams: $40 copay; Other Eye Exam Services: Not applicable; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: Not applicable; Eyeglass frames: Not applicable; Upgrades: Not applicable
Out-of-networkNot separately reported

Hearing

In-networkHearing Exams: $40 copay; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): $500–$1,975 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 applicable
In-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 applicable
In-networkOver-the-Counter (OTC) Items: Not applicable
Out-of-networkNot separately reported

Meals

Not applicable
In-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 $132 per month.

Maximum out-of-pocket (MOOP)

In-network$9,850
Combined in + outNot reported

Medical deductibles

In-network$0
Out-of-networkNot reported

Annual health deductible

Not separately reported

Combined network deductible

Not separately reported

Part D premium

$0 / month

Network & referrals

HMO · Referrals: Not required · Out-of-network coverage: Not reported

Prescription drugs5 tiers

Part D deductible

$450 / 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: 29% coinsurance · Preferred retail: 29% coinsurance · 30-day supply

Drug tier 5

Standard retail: 28% coinsurance · Preferred retail: 28% coinsurance · 30-day supply

Using this plan

Understand H9207-015-000

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

Jefferson Health Plans Giveback (HMO) is a 2027 HMO offered by Jefferson Health Plans in Southeastern PA. The plan record does not require referrals. Its listed inpatient copay stages total $2,250 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: $50 copay

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
Diagnostic Procedures/Tests: $25 copay
MRI, CT & PET imaging
Diagnostic Radiological Services: $450 copay
Outpatient hospital
Outpatient Hospital Services: $450 copay; Observation Services: $450 copay

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

Emergency & hospital care

Emergency room
$100 copay
Listed inpatient stages
$2,250 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 $132 per month.

Availability

Who can enroll

Service area
Southeastern PA (PA)
Plan type
HMO
Contract / plan
H9207-015
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: $40 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; Other Preventive Dental Services: $0 cost share; Restorative Services: $0 cost share; Endodontics: $0 cost share; Periodontics: $0 cost share; Prosthodontics, removable: $0 cost share; Maxillofacial Prosthetics: $0 cost share; Prosthodontics, fixed: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share
VisionEye Exams: $40 copay; Other Eye Exam Services: Not applicable; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: Not applicable; Eyeglass frames: Not applicable; Upgrades: Not applicable
HearingHearing Exams: $40 copay; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): $500–$1,975 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 H9207-015-000 available?

Jefferson Health Plans Giveback (HMO) is listed for Southeastern 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 H9207-015-000?

The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $9,850. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H9207-015-000?

The listed consolidated Part C and Part D premium is $0 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H9207-015-000?

The plan record lists $100 copay, waived when an admission meets the plan's stated timing rule.

Does H9207-015-000 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.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H9207-015-000 fits

Full CMS plan ID
H9207-015-000
Contract
H9207
Base plan code
H9207-015
Segment
000
Carrier
Jefferson Health Plans
Plan type
HMO
Service area
Southeastern 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
  • Bucks, PA
  • Carbon, PA
  • Chester, PA
  • Cumberland, PA
  • Dauphin, PA
  • Delaware, PA
  • Franklin, PA
  • Lancaster, PA
  • Lebanon, PA

8 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 20 county links

Same CMS contract

H9207-002-000 Jefferson Health Plans Prime (HMO) Southeastern PA, Central PA and Eastern PA · HMO H9207-004-000 Jefferson Health Plans Special (HMO D-SNP) Southeastern PA, Central PA and Eastern PA · HMO H9207-012-000 Jefferson Health Plans Complete (HMO) Southeastern PA, Central PA and Eastern PA · HMO H9207-016-000 Jefferson Health Plans Dual Pearl (HMO D-SNP) Southeastern PA · HMO H9207-017-000 Jefferson Health Plans Select (HMO D-SNP) Southeastern PA, Central PA and Eastern PA · HMO H9207-018-000 Jefferson Health Plans Elite (HMO) Southern New Jersey · HMO

About this code

What H9207-015-000 identifies

H9207-015-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H9207-015, H9207 015, or the compact full CMS ID H9207015000 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.