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

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

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Contact lenses

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

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Eyeglass frames

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

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Eyeglass lenses

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

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Eyeglasses (frames and lenses)

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

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Other

In-Network Vision	$0 copay
Out-of-Network Vision	30% coinsurance

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Routine eye exam

In-Network Vision	$0 copay
Out-of-Network Vision	30% coinsurance

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Upgrades

Vision	Not covered

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Transportation	Not 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 Facility	30% per stay

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Occupational therapy visit

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

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Physical therapy and speech and language therapy visit

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

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Cleaning

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

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Dental x-ray(s)

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

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Fluoride treatment

Preventive dental	Not covered

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Oral exam

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

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Out-of-Network Preventive care	30% coinsurance
In-Network Preventive care	$0 copay
Out-of-Network Outpatient hospital coverage	30% coinsurance per visit
In-Network Outpatient hospital coverage	$0-50 copay per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	Yes

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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 services	30% per stay

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Outpatient group therapy visit

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	30% coinsurance

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Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	30% coinsurance

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Outpatient individual therapy visit

Out-of-Network Mental health services	30% coinsurance
In-Network Mental health services	$0 copay

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Outpatient individual therapy visit with a psychiatrist

Out-of-Network Mental health services	30% coinsurance
In-Network Mental health services	$0 copay

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Chemotherapy

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	30% coinsurance

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Other Part B drugs

Out-of-Network Medicare Part B drugs	30% coinsurance
In-Network Medicare Part B drugs	20% coinsurance

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Diabetes supplies

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

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

Out-of-Network Medical equipment/supplies	30% coinsurance per item
In-Network Medical equipment/supplies	20% coinsurance per item

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

In-Network Medical equipment/supplies	0-20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

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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 coverage	30% per stay

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Fitting/evaluation

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

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Hearing aids

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

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Hearing exam

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

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

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Foot exams and treatment

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

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Routine foot care

Foot care (podiatry services)	Not covered

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Emergency

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

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Urgent care

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

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Primary

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

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Specialist

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

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Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$0-310 copay
Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance

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Diagnostic tests and procedures

Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$20 copay or 20% coinsurance

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Lab services

Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$0 copay or 20% coinsurance

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Outpatient x-rays

Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$0-15 copay

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Diagnostic services

Comprehensive dental	Not covered

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Endodontics

Comprehensive dental	Not covered

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Extractions

In-Network Comprehensive dental	30% coinsurance
Out-of-Network Comprehensive dental	30% coinsurance

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Non-routine services

Comprehensive dental	Not covered

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Periodontics

Comprehensive dental	Not covered

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Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	Not covered

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Restorative services

In-Network Comprehensive dental	30% coinsurance
Out-of-Network Comprehensive dental	30% coinsurance

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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.

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with H3864-030 Health Plan

Member Complaints and Changes in Plans Performance

Health Plan Customer Service Rating for PacificSource Medicare

Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

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:

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

Last updated on December 03, 2022

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.