PacificSource Medicare MyCare Choice 30 (HMO-POS)
Medicare Advantage Plan H3864-030 • 2026 • Bonner County, ID
PacificSource Medicare MyCare Choice 30 (HMO-POS) Medicare Advantage Plan H3864-030 • 2026 • Bonner County, ID
PacificSource Medicare MyCare Choice 30 is a Medicare Advantage HMO-POS plan offered by PacificSource Medicare for the 2026 plan year. It is identified by CMS Plan ID H3864-030 and uses a Health Maintenance Organization with a Point of Service (HMO-POS) provider network. The plan comes without prescription drug coverage.
PacificSource Medicare MyCare Choice 30 Overview
Plan Overview for H3864-030-0 |
|
|---|---|
| CMS Plan ID: | H3864-030-0 |
| Plan Type: | HMO-POS |
| Plan Year: | 2026 |
| Monthly Premium: | $0.00 Plus your Medicare Part B premium. |
| Medical Deductible: | $0.00 |
| Maximum Out-of-Pocket: | $4950.00 (In-Network) |
| Part B Give Back: | Not offered |
| Prescription Drug Coverage: | Not Included |
| Additional Benefits: | Dental, Vision, Hearing |
| Service Area: | Bonner County, ID |
| Enrollment (Nationwide) | 187 beneficiaries |
| Enrollment (CMS – Local) | 21 beneficiaries in Bonner County |
| Provided By: | PacificSource Medicare |
Coverage Overview for PacificSource Medicare MyCare Choice 30
PacificSource Medicare MyCare Choice 30 is a Medicare Advantage HMO-POS plan that includes Medicare Part A and Part B coverage, with limited access to out-of-network providers in certain situations. The monthly premium is $0.00, and costs are generally lower when services are received from in-network providers.
Primary care visits have a $0 copay | Out-of-network: $45 copay, 30% coinsurance, specialist visits come with a $0 copay | Out-of-network: $45 copay, 30% coinsurance, urgent care services carry a $50 copay, and ambulance transportation is $300 copay | Out-of-network: $300 copay. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $4950.00. After this limit is reached, in-network services are fully covered.
This plan is listed by CMS under Plan ID {title_plan_id}. A summary of cost sharing is provided below.
Out-of-Pocket Costs
PacificSource Medicare MyCare Choice 30 includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The table below outlines the most common in-network out-of-pocket costs associated with plan H3864-030.
This section outlines in-network costs for primary care and specialist office visits, along with related preventive services.
| Covered Service | In-Network Cost |
|---|---|
| Primary: | In-network: $0 copay | Out-of-network: $45 copay, 30% coinsurance |
| Specialist: | In-network: $0 copay | Out-of-network: $45 copay, 30% coinsurance |
This section outlines in-network costs for preventive and wellness services included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Annual wellness exam: | In-network: $0 copay |
| Telehealth benefit: | In-network: $0 copay |
| Routine chiropractic: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Fitness benefits: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Health education: | Not covered |
| Counseling services: | Not covered |
| Over-the-counter drug benefits: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Health transportation (non-emergency): | Not covered |
This section outlines in-network costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Covered Service | In-Network Cost |
|---|---|
| Diagnostic radiology services: | In-network: $0-$310 copay | Out-of-network: 30% coinsurance |
| Lab services: | In-network: 0%-20% coinsurance | Out-of-network: 30% coinsurance |
| Outpatient x-rays: | In-network: $0-$15 copay | Out-of-network: 30% coinsurance |
| Diagnostic tests and procedures: | In-network: $20 copay, 20% coinsurance | Out-of-network: 30% coinsurance |
This section outlines in-network costs for emergency services, urgent care, ambulance transportation, inpatient hospital stays, and skilled nursing facility care.
| Covered Service | In-Network Cost |
|---|---|
| Emergency room care: | $120 copay |
| Worldwide emergency care: | $120 copay |
| Urgent care: | $50 copay |
| Inpatient hospital care: | In-network: | Tier 1 | $425 per day for days 1-5 | $0 per day for days 6-90 | $0 per stay | Out-of-network: | 30% per stay |
| Skilled Nursing Facility: | In-network: | Tier 1 | $0 per day for days 1-20 | $203 per day for days 21-100 | Out-of-network: | 30% per stay |
| Ground ambulance: | In-network: $300 copay | Out-of-network: $300 copay |
This section outlines in-network costs for mental health services, including outpatient therapy and inpatient psychiatric care.
| Covered Service | In-Network Cost |
|---|---|
| Outpatient individual therapy: | In-network: $0 copay | Out-of-network: 30% coinsurance |
| Outpatient group therapy: | In-network: $0 copay | Out-of-network: 30% coinsurance |
| Inpatient psychiatric hospital care: | In-network: | Tier 1 | $425 per day for days 1-5 | $0 per day for days 6-90 | $0 per stay | Out-of-network: | 30% per stay |
This section outlines in-network costs for rehabilitation services, including physical therapy, speech and language therapy, and occupational therapy.
| Covered Service | In-Network Cost |
|---|---|
| Physical therapy and speech and language therapy: | In-network: $0 copay | Out-of-network: $45 copay, 30% coinsurance |
| Occupational therapy: | In-network: $0 copay | Out-of-network: $45 copay, 30% coinsurance |
This section outlines in-network costs for medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Covered Service | In-Network Cost |
|---|---|
| Diabetes supplies: | In-network: 20% coinsurance | Out-of-network: 30% coinsurance |
| Durable medical equipment: | In-network: 20% coinsurance | Out-of-network: 30% coinsurance |
| Prosthetics: | In-network: 0%-20% coinsurance | Out-of-network: 30% coinsurance |
This section outlines in-network cost sharing for chemotherapy and other Medicare Part B-covered drugs.
| Covered Service | In-Network Cost |
|---|---|
| Chemotherapy: | In-network: 0%-20% coinsurance | Out-of-network: $35 copay, 30% coinsurance |
| Other Part B drugs (Medicare-covered): | In-network: 0%-20% coinsurance | Out-of-network: $35 copay, 30% coinsurance |
This section outlines in-network cost sharing for dental services, including preventive care, exams, x-rays, cleanings, and comprehensive dental procedures.
| Covered Service | In-Network Cost |
|---|---|
| Oral exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Dental x-rays: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Cleaning: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Periodontics: | In-network: $0 copay | Out-of-network: 50% coinsurance |
| Endodontics: | In-network: $0 copay | Out-of-network: 50% coinsurance |
| Restorative services: | In-network: $0 copay | Out-of-network: 50% coinsurance |
| Implant services: | In-network: $0 copay | Out-of-network: 50% coinsurance |
| Orthodontics: | Not covered |
| Oral/Maxillofacial surgery: | In-network: $0 copay | Out-of-network: 50% coinsurance |
This section outlines in-network cost sharing for vision services, including eye exams, eyeglasses, and contact lenses.
| Covered Service | In-Network Cost |
|---|---|
| Routine eye exam: | In-network: $0 copay | Out-of-network: 30% coinsurance |
| Contact lenses: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass frames only: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass lenses only: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglasses (frames & lenses): | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Upgrades: | Not covered |
This section outlines in-network cost sharing for hearing-related services, including exams, fittings, and hearing aids.
| Covered Service | In-Network Cost |
|---|---|
| Hearing exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Fitting/evaluation: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Prescription hearing aids: | In-network: $599-$999 copay | Out-of-network: $599-$999 copay |
| OTC hearing aids: | Not covered |
This section outlines in-network cost sharing for additional and special needs services that may be included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Adult day health services: | Not covered |
| Home-based palliative care: | Not covered |
| Personal emergency response system: | Not covered |
| Weight management programs: | Not covered |
| Wigs for chemotherapy-related hair loss: | Not covered |
| Alternative therapies: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Massage therapy: | Not covered |
| Home/bathroom safety devices: | Not covered |
Certain preventive services are covered 100% by PacificSource Medicare MyCare Choice 30 as a Part B benefit.
Prescription Drug Coverage
This plan does not include a Medicare Part D plan for prescriptions.
CMS 5-Star Ratings
CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2026 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Is there a monthly premium for this plan in 2026?
For 2026, the monthly premium is $0.00. Medicare Part B premiums apply in addition to this amount.
What is the in-network MOOP for plan H3864-030?
For 2026, the in-network maximum out-of-pocket is $4950.00. The plan pays 100% of covered in-network services beyond this amount.
What is the total enrollment for plan H3864-030?
Total enrollment is 187 beneficiaries based on the latest CMS data.
Is there a Part D deductible for this plan?
The Part D deductible is $0.00.
Contact Information for PacificSource Medicare
| Contact Type | Details |
|---|---|
| Website: | PacificSource Medicare Plan Page |
| New Members: | 1-888-863-3637 |
| Existing Members: | 1-888-863-3637 |
| Plan Address: | 2965 NE Conners Ave | Bend, OR 97701 |
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at medicare.gov.
- CMS.gov, Landscape Source Files — Last accessed May 2, 2026
- CMS.gov, Medicare Part C & D Performance — Last accessed May 2, 2026
- CMS.gov, Plan Benefits Package — Last accessed May 2, 2026
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County — Last accessed May 2, 2026
Data sources and methodology documentation..
- PacificSource Medicare (official source), http://www.Medicare.PacificSource.com — Last accessed October 13, 2025
- CMS.gov, "Medicare Advantage Plan Fact Sheet" — Last accessed 25 May, 2025
- Medicare.gov, "Joining a plan" — Last accessed 25 May, 2025
- Medicare.gov, "Your coverage options" — Last accessed 25 May, 2025
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