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2023 PacificSource Medicare MyCare Choice 30 (HMO-POS)

PacificSource Medicare MyCare Choice 30 (HMO-POS) H3864-030 is a 2023 Medicare Advantage Plan or Part-C by PacificSource Medicare available to residents in Idaho and Oregon. This plan does not provide extra prescription drug (Part-D) coverage. PacificSource Medicare PacificSource Medicare MyCare Choice 30 (HMO-POS) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $3,950 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $3,950 out-of-pocket. This can be an extremely nice safety net.

PacificSource Medicare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for PacificSource Medicare MyCare Choice 30 (HMO-POS) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from PacificSource Medicare and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all the benefits of Original Medicare from PacificSource Medicare except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in Idaho or Medicare Advantage in Oregon.



2023 PacificSource Medicare Medicare Advantage Plan Overview

Name:PacificSource Medicare MyCare Choice 30 (HMO-POS)
Plan ID:H3864 030 0
Provider:PacificSource Medicare
Year:2023
Type:Local HMO *
Combined Premium (C+D):$0/mo
MOOP:$3,950/yr
Similar Plan: H3864-032




What type of plan is PacificSource Medicare MyCare Choice 30 (HMO-POS)

PacificSource Medicare MyCare Choice 30 (HMO-POS) is a Local HMO *. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your primary care physician will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your primary care physician approval, called a referral. Services received from an out-of-network provider are not typically covered.

With a HMO-POS point-of-service you have the option to go out-of-network or see a specialist without a referral. But, you may pay more for out-of-network care you receive than from an in-network provider.

How much does PacificSource Medicare MyCare Choice 30 (HMO-POS) cost?


Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. PacificSource Medicare charges a $0 premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.


MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. PacificSource Medicare MyCare Choice 30 (HMO-POS) by PacificSource Medicare MOOP is $3,950. Once you spend $3,950 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.





2023 Summary of Benefits


The benefit information provided is a summary of what PacificSource Medicare MyCare Choice 30 (HMO-POS) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from PacificSource Medicare helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)Covered


Contact lenses


In-Network Vision$0 copay
Out-of-Network Vision$0 copay


Eyeglass frames


In-Network Vision$0 copay
Out-of-Network Vision$0 copay


Eyeglass lenses


Out-of-Network Vision$0 copay
In-Network Vision$0 copay


Eyeglasses (frames and lenses)


Out-of-Network Vision$0 copay
In-Network Vision$0 copay


Other


In-Network Vision$0 copay
Out-of-Network Vision30% coinsurance


Routine eye exam


In-Network Vision$0 copay
Out-of-Network Vision30% coinsurance


Upgrades


VisionNot covered



TransportationNot covered
In-Network Skilled Nursing Facility$0 per day for days 1 through 20
$196 per day for days 21 through 100
Out-of-Network Skilled Nursing Facility30% per stay


Occupational therapy visit


Out-of-Network Rehabilitation services$45 copay or 30% coinsurance
In-Network Rehabilitation services$0 copay


Physical therapy and speech and language therapy visit


Out-of-Network Rehabilitation services$45 copay or 30% coinsurance
In-Network Rehabilitation services$0 copay


Cleaning


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental$0 copay


Dental x-ray(s)


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental$0 copay


Fluoride treatment


Preventive dentalNot covered


Oral exam


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental$0 copay



Out-of-Network Preventive care30% coinsurance
In-Network Preventive care$0 copay
Out-of-Network Outpatient hospital coverage30% coinsurance per visit
In-Network Outpatient hospital coverage$0-50 copay per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsYes


Inpatient hospital - psychiatric


In-Network Mental health services$230 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-Network Mental health services30% per stay


Outpatient group therapy visit


In-Network Mental health services$0 copay
Out-of-Network Mental health services30% coinsurance


Outpatient group therapy visit with a psychiatrist


In-Network Mental health services$0 copay
Out-of-Network Mental health services30% coinsurance


Outpatient individual therapy visit


Out-of-Network Mental health services30% coinsurance
In-Network Mental health services$0 copay


Outpatient individual therapy visit with a psychiatrist


Out-of-Network Mental health services30% coinsurance
In-Network Mental health services$0 copay


Chemotherapy


In-Network Medicare Part B drugs20% coinsurance
Out-of-Network Medicare Part B drugs30% coinsurance


Other Part B drugs


Out-of-Network Medicare Part B drugs30% coinsurance
In-Network Medicare Part B drugs20% coinsurance


Diabetes supplies


In-Network Medical equipment/supplies20% coinsurance per item
Out-of-Network Medical equipment/supplies30% coinsurance per item


Durable medical equipment (e.g., wheelchairs, oxygen)


Out-of-Network Medical equipment/supplies30% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item


Prosthetics (e.g., braces, artificial limbs)


In-Network Medical equipment/supplies0-20% coinsurance per item
Out-of-Network Medical equipment/supplies30% coinsurance per item



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$3,950 In-network
In-Network Inpatient hospital coverage$250 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-Network Inpatient hospital coverage30% per stay


Fitting/evaluation


Out-of-Network Hearing$0 copay
In-Network Hearing$0 copay


Hearing aids


Out-of-Network Hearing$599-999 copay
In-Network Hearing$599-999 copay


Hearing exam


In-Network Hearing$30 copay
Out-of-Network Hearing30% coinsurance



Health plan deductible$0
Out-of-Network Ground ambulance$300 copay
In-Network Ground ambulance$300 copay


Foot exams and treatment


In-Network Foot care (podiatry services)$0 copay
Out-of-Network Foot care (podiatry services)30% coinsurance


Routine foot care


Foot care (podiatry services)Not covered


Emergency


Emergency care/Urgent care$110 copay per visit (always covered)


Urgent care


Emergency care/Urgent care$40 copay per visit (always covered)


Primary


In-Network Doctor visits$0 copay
Out-of-Network Doctor visits$45 copay or 30% coinsurance per visit


Specialist


In-Network Doctor visits$0 copay
Out-of-Network Doctor visits$45 copay or 30% coinsurance per visit


Diagnostic radiology services (e.g., MRI)


In-Network Diagnostic procedures/lab services/imaging$0-310 copay
Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance


Diagnostic tests and procedures


Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance
In-Network Diagnostic procedures/lab services/imaging$20 copay or 20% coinsurance


Lab services


Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance
In-Network Diagnostic procedures/lab services/imaging$0 copay or 20% coinsurance


Outpatient x-rays


Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance
In-Network Diagnostic procedures/lab services/imaging$0-15 copay


Diagnostic services


Comprehensive dentalNot covered


Endodontics


Comprehensive dentalNot covered


Extractions


In-Network Comprehensive dental30% coinsurance
Out-of-Network Comprehensive dental30% coinsurance


Non-routine services


Comprehensive dentalNot covered


Periodontics


Comprehensive dentalNot covered


Prosthodontics, other oral/maxillofacial surgery, other services


Comprehensive dentalNot covered


Restorative services


In-Network Comprehensive dental30% coinsurance
Out-of-Network Comprehensive dental30% coinsurance



In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?No




PacificSource Medicare MyCare Choice 30 (HMO-POS) Reviews


Is PacificSource Medicare MyCare Choice 30 (HMO-POS) a good plan? PacificSource Medicare MyCare Choice 30 (HMO-POS) received a 3.5 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance. Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare PacificSource Medicare MyCare Choice 30 Reviews among several different plans.

2022 Overall Rating
Part C Summary Rating
Part-D Summary 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


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Pain Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with H3864-030 Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for PacificSource Medicare

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes


Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for PacificSource Medicare MyCare Choice 30 (HMO-POS) requires you to live in that plan’s service area. The service area is listed below:

State: Idaho Medicare

Oregon Medicare

Washington Medicare

Montana Medicare
County:Bonner County MA Plans

Boundary County MA Plans

Clackamas County MA Plans

Clark County MA Plans

Kootenai County MA Plans

Multnomah County MA Plans

Pierce County MA Plans

Spokane County MA Plans

Washington County MA Plans

Yellowstone County MA Plans



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How much does PacificSource Medicare MyCare Choice 30 (HMO-POS) cost?

PacificSource Medicare charges a $0 monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage. The premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

How much is PacificSource Medicare MyCare Choice 30 (HMO-POS) MOOP?

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. PacificSource Medicare MyCare Choice 30 (HMO-POS) by PacificSource Medicare MOOP is $3,950. Once you spend $3,950 you will pay nothing for Part A or Part B covered services.

What type of plan is PacificSource Medicare MyCare Choice 30 (HMO-POS)?

PacificSource Medicare MyCare Choice 30 (HMO-POS) is a Local HMO *. With a health maintenance organization you will be required to receive most of your health care from an in-network provider. HMOs require that you select a primary care physician (PCP).

With a HMO-POS point-of-service you have the option to go out-of-network or see a specialist without a referral. But, you may pay more for out-of-network care you receive than from an in-network provider.

Is PacificSource Medicare MyCare Choice 30 (HMO-POS) a good plan?

PacificSource Medicare MyCare Choice 30 (HMO-POS) received a 3.5 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance.



Source:CMS. Data as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

      Site Search:

MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.

Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

Every year, Medicare evaluates plans based on a 5-star rating system.