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

2027 Medicare plan code

H9572-003

Medicare Plan

Medicare Plus Blue Assure (PPO) · Blue Cross Blue Shield of Michigan · Local PPO · Region 4

Full CMS plan ID: H9572-003-004

H9572-003-004 is the full CMS identifier for the H9572-003 Medicare plan. Common searches include H9572 003 and H9572003.

2027

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

● CMS 2027 plan record

Medicare Plus Blue Assure (PPO)

H9572-003-004 Region 4 Local PPO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–7 $225 / day
Days 8–90 $0 / day
Total of listed copays · 7 charged days $1,575
Out-of-network

Tier 1: $0 per stay; 30% coinsurance

Point of service

Not separately reported

02

Emergency transport

Ambulance

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

Emergency services

Emergency room

$130 copay

Waived if admitted within 3 days

04

Medical maximum

Maximum out-of-pocket

In-network$4,000
Combined in + out$6,200
05

Skilled care at home

Home health

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

Monthly cost

Premium & giveback

Part C premium$183.40 / month
Consolidated C + D$217.50 / 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: 30% coinsurance

Specialist

In-networkPhysician Specialist Services: $10 copay
Out-of-network7d: 30% coinsurance

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: 30% coinsurance; 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–$75 copay
Out-of-network8a1: $0 copay + 30% coinsurance

Laboratory services

In-networkLab Services: $0–$20 copay
Out-of-network8a2: 30% coinsurance

X-rays & standard imaging

In-networkOutpatient X-Ray Services: $35–$75 copay
Out-of-network8b3: 30% coinsurance

MRI, CT & PET imaging

In-networkDiagnostic Radiological Services: $75 copay
Out-of-network8b1: 30% coinsurance
Urgent & hospital care6 benefits

Urgent care

In-networkUrgently Needed Services: $0–$40 copay
Out-of-networkNot separately reported

Emergency room

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

Ground ambulance

In-network$250 copay
Out-of-network$250 copay + 30% coinsurance

Air ambulance

In-network$250 copay
Out-of-network$250 copay + 30% coinsurance

Outpatient hospital

In-networkOutpatient Hospital Services: $75–$150 copay; Observation Services: $130 copay
Out-of-network9a1: 30% coinsurance; 9a2: 30% coinsurance

Outpatient surgery / ASC

In-networkAmbulatory Surgical Center (ASC) Services: $0–$75 copay
Out-of-network9b: 30% coinsurance
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: $15 copay; Intensive Cardiac Rehabilitation Services: $15 copay; Pulmonary Rehabilitation Services: $10 copay; SET for PAD Services: $15 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: 30% coinsurance; 3-2: 30% coinsurance; 3-3: 30% coinsurance; 3-4: 30% coinsurance

Occupational therapy

In-networkOccupational Therapy Services: $30 copay
Out-of-network7c: 30% coinsurance

Physical & speech therapy

In-networkPhysical Therapy and Speech-Language Pathology Services: $30 copay
Out-of-network7i: 30% coinsurance
Behavioral health2 benefits

Mental health services

In-networkPartial Hospitalization Program: $55 copay; Individual Sessions for Mental Health Specialty Services: $20 copay; Group Sessions for Mental Health Specialty Services: $20 copay; Individual Sessions for Psychiatric Services: $20 copay; Group Sessions for Psychiatric Services: $20 copay; Inpatient psychiatric hospital: Tier 1: $100 / day for days 1–7; $0 / day for days 8–90
Out-of-network5a: 30% coinsurance; 7e1: 30% coinsurance; 7e2: 30% coinsurance; 7h1: 30% coinsurance; 7h2: 30% coinsurance; Inpatient psychiatric hospital: Tier 1: 30% coinsurance

Substance use treatment

In-networkIntensive Outpatient Program Services: $55 copay; Individual Sessions for Outpatient Substance Abuse: $10 copay; Group Sessions for Outpatient Substance Abuse: $10 copay
Out-of-network5b: 30% coinsurance; 9c1: 30% coinsurance; 9c2: 30% coinsurance
Specialty care2 benefits

Podiatry

In-networkPodiatry Services: $10 copay; 7f(NMC): Not applicable
Out-of-network7f: 30% coinsurance

Chiropractic

In-networkChiropractic Services: $15 copay
Out-of-network7b: 30% coinsurance
Supplemental benefits7 benefits

Dental

In-networkMedicare Dental Services: $0–$10 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; Restorative Services: $0 cost share; Endodontics: $0 cost share; Periodontics: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share
Out-of-network16a: 30% coinsurance; 16b1: 50% coinsurance; 16b2: 50% coinsurance; 16b4: 50% coinsurance; 16b5: 50% coinsurance; 16c1: 50% coinsurance; 16c2: 50% coinsurance; 16c3: 50% coinsurance; 16c8: 50% coinsurance

Vision

In-networkEye Exams: $0–$10 copay; Other Eye Exam Services: Not applicable; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): Not applicable; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: Not applicable
Out-of-network17a: 30% coinsurance; 17a1: 50% coinsurance; 17b: 30% coinsurance; 17b1: 50% coinsurance; 17b3: 50% coinsurance; 17b4: 50% coinsurance

Hearing

In-networkHearing Exams: $0–$10 copay; Prescription Hearing Aids (all types): $495–$1,695 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: 30% coinsurance; 18a1: $0 cost share; 18a2: $0 cost share; 18b1: $495–$1,695 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

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

Premium & Part B giveback

$183.40 Part C premium / month · CMS reports no Part B premium reduction for this plan.

Maximum out-of-pocket (MOOP)

In-network$4,000
Combined in + out$6,200

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Annual health deductible

$0

Combined network deductible

Not separately reported

Part D premium

$34.10 / month

Network & referrals

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

Prescription drugs5 tiers

Part D deductible

$100 / year

Drug tier 1

Standard retail: $5 copay · Preferred retail: $0 copay · 31-day supply

Drug tier 2

Standard retail: $12 copay · Preferred retail: $5 copay · 31-day supply

Drug tier 3

Standard retail: 24% coinsurance · Preferred retail: 20% coinsurance · 31-day supply

Drug tier 4

Standard retail: 28% coinsurance · Preferred retail: 28% coinsurance · 31-day supply

Drug tier 5

Standard retail: 32% coinsurance · Preferred retail: 32% coinsurance · 31-day supply

Using this plan

Understand H9572-003-004

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

Medicare Plus Blue Assure (PPO) is a 2027 Local PPO offered by Blue Cross Blue Shield of Michigan in Region 4. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $1,575 across 7 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: $10 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–$75 copay
MRI, CT & PET imaging
Diagnostic Radiological Services: $75 copay
Outpatient hospital
Outpatient Hospital Services: $75–$150 copay; Observation Services: $130 copay

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

Emergency & hospital care

Emergency room
$130 copay
Listed inpatient stages
$1,575 total

7 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 no Part B premium reduction for this plan.

Availability

Who can enroll

Service area
Region 4 (MI)
Plan type
Local PPO
Contract / plan
H9572-003
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–$10 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; Restorative Services: $0 cost share; Endodontics: $0 cost share; Periodontics: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share
VisionEye Exams: $0–$10 copay; Other Eye Exam Services: Not applicable; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): Not applicable; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: Not applicable
HearingHearing Exams: $0–$10 copay; Prescription Hearing Aids (all types): $495–$1,695 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Over-the-counter allowanceOver-the-Counter (OTC) Items: $0 cost share
Fitness & wellnessFitness Benefit: $0 cost share
MealsMeal Benefit: $0 cost share

Plan-specific answers

Frequently asked questions

Where is H9572-003-004 available?

Medicare Plus Blue Assure (PPO) is listed for Region 4 (MI). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H9572-003-004?

The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $4,000. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H9572-003-004?

The listed consolidated Part C and Part D premium is $217.50 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H9572-003-004?

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

Does H9572-003-004 report extra benefits?

Yes. CMS reports dental, vision, hearing, over-the-counter allowance, fitness & wellness, and other supplemental benefits. 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 H9572-003-004 fits

Full CMS plan ID
H9572-003-004
Contract
H9572
Base plan code
H9572-003
Segment
004
Carrier
Blue Cross Blue Shield of Michigan
Plan type
Local PPO
Service area
Region 4 (MI)

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.

  • Antrim, MI
  • Benzie, MI
  • Cass, MI
  • Clinton, MI
  • Delta, MI
  • Dickinson, MI
  • Emmet, MI
  • Genesee, MI
  • Gogebic, MI
  • Grand Traverse, MI
  • Houghton, MI
  • Iron, MI

17 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 29 county links

Same CMS contract

H9572-003-001 Medicare Plus Blue Assure (PPO) Region 1 · Local PPO H9572-003-002 Medicare Plus Blue Assure (PPO) Region 2 · Local PPO H9572-003-003 Medicare Plus Blue Assure (PPO) Region 3 · Local PPO H9572-003-006 Medicare Plus Blue Assure (PPO) Region 6 · Local PPO H9572-001-001 Medicare Plus Blue Signature (PPO) Region 1 · Local PPO H9572-001-002 Medicare Plus Blue Signature (PPO) Region 2 · Local PPO H9572-001-003 Medicare Plus Blue Signature (PPO) Region 3 · Local PPO H9572-001-004 Medicare Plus Blue Signature (PPO) Region 4 · Local PPO

About this code

What H9572-003-004 identifies

H9572-003-004 is a Contract Year 2027 Medicare plan segment code. Searches written as H9572-003, H9572 003, or the compact full CMS ID H9572003004 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.