Medicare Plans

Open Medicare Plan Data.

PacificSource Medicare Idaho Basic (HMO-POS) Medicare Advantage Plan H3864-050 • 2027

CMS Rating: ☆☆☆☆☆ (3.0 out of 5 stars*)
Monthly Premium
$0.00Plus Part B premium.
Medical Deductible
$0.00
Maximum Out-of-Pocket
$7150.00In-network
Part B Giveback
−$60.00 reduction
Prescription Coverage
Not Included
Additional Benefits
Dental, Vision, Hearing
Service Area
See List
Total Enrollment
0 beneficiaries
Last update:

PacificSource Medicare Idaho Basic (HMO-POS) Introduction

This Medicare Advantage HMO-POS plan, PacificSource Medicare Idaho Basic, is offered by PacificSource Medicare and uses a Health Maintenance Organization with a Point of Service (HMO-POS) provider network. It comes without prescription drug coverage. For the 2027 plan year, the monthly premium is $0.00, the medical deductible is $0.00, and the in-network maximum out-of-pocket is $7150.00. The plan is identified by CMS Plan ID H3864-050.

Plan Benefits

Cost-sharing for PacificSource Medicare Idaho Basic includes out-of-pocket expenses for covered healthcare services. The following tables provide a summary of typical in-network out-of-pocket costs for plan H3864-050.

Compare 2027 plan benefits with 2026.

Office Visits

Office visit costs by plan year.
Covered Service 2027 2026
Primary care In-network: $0 copay
Out-of-network: 50% coinsurance		 Coming soon
Specialist In-network: $0-$45 copay
Out-of-network: 50% coinsurance		 Coming soon

Preventive and Wellness Services

Preventive and wellness service costs and benefits by plan year.
Covered Service 2027 2026
Annual wellness exam In-network: $0 copay
Out-of-network: 50% coinsurance		 Coming soon
Telehealth benefit In-network: $0-$45 copay Coming soon
Routine chiropractic Not covered Coming soon
Fitness benefits Coming soon Coming soon
Health education Not covered Coming soon
Counseling services Not covered Coming soon
Over-the-counter drug benefits Not covered Coming soon
Health transportation (non-emergency) Coming soon Coming soon

Diagnostic, Lab, and Imaging Services

Diagnostic, laboratory, and imaging service costs by plan year.
Covered Service 2027 2026
Diagnostic radiology services In-network: $0 copay, 20% coinsurance
Out-of-network: 50% coinsurance		 Coming soon
Lab services In-network: $0 copay, 20% coinsurance
Out-of-network: 50% coinsurance		 Coming soon
Outpatient x-rays In-network: $0-$15 copay
Out-of-network: 50% coinsurance		 Coming soon
Diagnostic tests and procedures In-network: $15 copay, 20% coinsurance
Out-of-network: 50% coinsurance		 Coming soon

Emergency and Urgent Care Services

Emergency, urgent care, hospital, ambulance, and skilled nursing costs by plan year.
Covered Service 2027 2026
Emergency room care $130 copay Coming soon
Worldwide emergency care Coming soon Coming soon
Urgent care $50 copay Coming soon
Inpatient hospital care In-network:
Tier 1
$550 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Out-of-network:
50% per stay		 Coming soon
Skilled Nursing Facility In-network:
Tier 1
$0 per day for days 1-20
$221 per day for days 21-100
Out-of-network:
50% per stay		 Coming soon
Ground ambulance In-network: $400 copay
Out-of-network: $400 copay		 Coming soon

Mental Health Services

Mental health therapy and inpatient psychiatric care costs by plan year.
Covered Service 2027 2026
Outpatient individual therapy In-network: $25 copay
Out-of-network: 50% coinsurance		 Coming soon
Outpatient group therapy In-network: $25 copay
Out-of-network: 50% coinsurance		 Coming soon
Inpatient psychiatric hospital care In-network:
Tier 1
$550 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Out-of-network:
50% per stay		 Coming soon

Rehabilitation Services

Physical, speech, and occupational therapy costs by plan year.
Covered Service 2027 2026
Physical therapy and speech and language therapy In-network: $25 copay
Out-of-network: 50% coinsurance		 Coming soon
Occupational therapy In-network: $20 copay
Out-of-network: 50% coinsurance		 Coming soon

Medical Equipment and Supplies

Diabetes supplies, durable medical equipment, and prosthetic costs by plan year.
Covered Service 2027 2026
Diabetes supplies In-network: 20% coinsurance
Out-of-network: 50% coinsurance		 Coming soon
Durable medical equipment In-network: 20% coinsurance
Out-of-network: 50% coinsurance		 Coming soon
Prosthetics In-network: 0%-20% coinsurance
Out-of-network: 50% coinsurance		 Coming soon

Medicare Part B Drugs

Chemotherapy and other Medicare Part B-covered drug costs by plan year.
Covered Service 2027 2026
Chemotherapy In-network: 0%-20% coinsurance
Out-of-network: $35 copay, 50% coinsurance		 Coming soon
Other Part B drugs (Medicare-covered) In-network: 0%-20% coinsurance
Out-of-network: $35 copay, 50% coinsurance		 Coming soon

Dental Services

Preventive and comprehensive dental service costs by plan year.
Covered Service 2027 2026
Oral exam In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 Coming soon
Dental x-rays In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 Coming soon
Cleaning In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 Coming soon
Periodontics In-network: 50% coinsurance
Out-of-network: 50% coinsurance		 Coming soon
Endodontics In-network: 50% coinsurance
Out-of-network: 50% coinsurance		 Coming soon
Restorative services In-network: 50% coinsurance
Out-of-network: 50% coinsurance		 Coming soon
Implant services Not covered Coming soon
Orthodontics Not covered Coming soon
Oral/Maxillofacial surgery In-network: 50% coinsurance
Out-of-network: 50% coinsurance		 Coming soon

Vision Services

Routine eye exams, contact lenses, and eyewear costs by plan year.
Covered Service 2027 2026
Routine eye exam In-network: $0 copay
Out-of-network: 50% coinsurance		 Coming soon
Contact lenses In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 Coming soon
Eyeglass frames only In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 Coming soon
Eyeglass lenses only In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 Coming soon
Eyeglasses (frames & lenses) In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 Coming soon
Upgrades Not covered Coming soon

Hearing Services

Hearing exams, fittings, and hearing aid costs by plan year.
Covered Service 2027 2026
Hearing exam In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 Coming soon
Fitting/evaluation In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance		 Coming soon
Prescription hearing aids In-network: $599-$999 copay
Out-of-network: $599-$999 copay		 Coming soon
OTC hearing aids Not covered Coming soon

Additional and Special Needs Services

Additional and special needs service costs and benefits by plan year.
Covered Service 2027 2026
Adult day health services Not covered Coming soon
Home-based palliative care Not covered Coming soon
Personal emergency response system Coming soon Coming soon
Weight management programs Not covered Coming soon
Wigs for chemotherapy-related hair loss Coming soon Coming soon
Alternative therapies Not covered Coming soon
Massage therapy Not covered Coming soon
Home/bathroom safety devices Not covered Coming soon

Certain preventive services are covered 100% by PacificSource Medicare Idaho Basic as a Part B benefit.

Prescription Drug Coverage

This plan does not include a Medicare Part D plan for prescriptions.

CMS 5-Star Performance Ratings (Contract ID: H3864)

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.

2027 Medicare Star Ratings for Contract H3864
CMS Measure Star Rating
2027 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 ☆☆☆☆☆

Frequently Asked Questions

Here are some of the most frequently asked questions about this plan (click to open).

Frequently Asked Questions About PacificSource Medicare Idaho Basic (HMO-POS)

What is the monthly premium for PacificSource Medicare Idaho Basic (HMO-POS)?

The 2027 monthly premium is $0.00. The Medicare Part B premium is paid separately.

What is the in-network MOOP for plan H3864-050?

For 2027, the in-network maximum out-of-pocket is $7150.00. The plan pays 100% of covered in-network services beyond this amount.

What is the total enrollment for plan H3864-050?

Total enrollment is 0 beneficiaries based on the latest CMS data.

What is the Part D deductible for plan H3864-050?

The plan’s Part D deductible is $0.00, applied to covered prescription drug costs.

Medicare Plan Data Sources and Methodology
Primary CMS datasets used for this Medicare Advantage Plan resource.
Data Source Publisher CMS Version
Landscape Source Files Centers for Medicare & Medicaid Services CY2027 Landscape (202609.1)
Medicare Part C & D Performance Centers for Medicare & Medicaid Services 2027 Star Ratings Data Tables
Plan Benefits Package Centers for Medicare & Medicaid Services PBP Benefits-2027
Monthly Enrollment by Contract/Plan/State/County Centers for Medicare & Medicaid Services 2026-09

Data sources and methodology documentation.

Official plan information and secondary Medicare references.
Publisher Reference Last Accessed
PacificSource Medicare (official source) http://www.Medicare.PacificSource.com October 4, 2026
CMS.gov Medicare Advantage Plan Fact Sheet 25 May, 2025
AARP.org The Big Choice: Original Medicare vs. Medicare Advantage 25 May, 2025
Medicare.gov Your coverage options 25 May, 2025

MedicarePlans.com is an independent informational resource and is not affiliated with or endorsed by the U.S. Government or the federal Medicare program.

Data provenance documentation is maintained in alignment with the U.S. Core Data for Interoperability (USCDI) Provenance standard.