Imperial Courage Plan (HMO)

Available to residents of Sutter County, CA for 2027. Contract H5496, plan 016, segment 0.

2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.

New for 2027. This plan has no 2026 predecessor in the CMS crosswalk. Every CA plan’s 2026–2027 changes →

Plan details

Monthly premium (Part C + D)	$0.00
— medical (Part C) part	$0.00
— drug (Part D) part	—?
Part B premium reduction (giveback)	$85.00 a month?You must continue to pay your Medicare Part B premium.
Health plan deductible (in-network)	None
In-network out-of-pocket maximum	$2,999.00?
Drug deductible	this plan has no drug coverage
Plan type	HMO?
Contract / plan	H5496-016-0
Offered by	Imperial Health Plan of California, Inc.
Parent organization	Imperial Health Plan of California
Pharmacy search	www.imperialhealthplan.com
Member services	(800)838-5914TTY 711

CMS star ratings

Overall: 4 out of 5 stars for Overall
Health plan (Part C): 3.5 out of 5 stars for Health plan (Part C)
Drug plan (Part D): 4.5 out of 5 stars for Drug plan (Part D)

Published per contract — every plan under contract H5496 shares this rating.

Plan health benefits

Service	In-network
Doctor visits
Primary care doctor	$0 copay
Specialist	$5 copay(authorization and referral required)
Other health care professional	$5 copay(authorization and referral required)
Additional telehealth services	$0 copay(authorization and referral required)
Preventive care
Medicare-covered preventive services	$0 copay
Annual physical exam	Not covered
Kidney disease education	$0 copay(authorization and referral required)
Glaucoma screening	$0 copay(authorization required)
Diabetes self-management training	$0 copay(authorization required)
Diagnostic tests, labs and imaging
Diagnostic tests and procedures	$0 copay(authorization and referral required)
Lab services	$0 copay(authorization and referral required)
Diagnostic radiology (e.g. MRI, CT)	$0 copay(authorization and referral required)
Therapeutic radiology	20% coinsurance(authorization and referral required)
Outpatient x-rays	$0 copay(authorization and referral required)
Emergency and urgent care
Emergency room	$125 copay
Urgent care	$0 copay
Worldwide emergency coverage	$0 copay · $50,000 plan limit
Worldwide urgent care	$20 copay · $50,000 plan limit
Worldwide emergency transportation	Not covered
Hospital care
Inpatient hospital stay	$150 per day for days 1–5; $0 per day for days 6–90(authorization and referral required)
Outpatient hospital services	$200 copay(authorization and referral required)
Outpatient observation	$200 copay(authorization and referral required)
Ambulatory surgical center	$200 copay(authorization and referral required)
Outpatient blood services	$0 copay(authorization and referral required)
Skilled nursing and home health
Skilled nursing facility	$0 per day for days 1–20; $200 per day for days 21–100(authorization and referral required)
Home health care	$10 copay(authorization and referral required)
Kidney dialysis	20% coinsurance(authorization and referral required)
Rehabilitation
Occupational therapy	$10 copay(authorization and referral required)
Physical therapy and speech-language therapy	20% coinsurance(authorization and referral required)
Cardiac rehabilitation	20% coinsurance(authorization and referral required)
Pulmonary rehabilitation	20% coinsurance(authorization and referral required)
Mental health and substance use
Inpatient psychiatric hospital stay	$150 per day for days 1–5; $0 per day for days 6–90(authorization and referral required)
Outpatient mental health, individual session	20% coinsurance(authorization and referral required)
Outpatient mental health, group session	20% coinsurance(authorization and referral required)
Psychiatrist, individual session	$0 copay(authorization and referral required)
Psychiatrist, group session	$0 copay(authorization and referral required)
Partial hospitalization	20% coinsurance(authorization and referral required)
Intensive outpatient program	20% coinsurance
Outpatient substance use, individual session	20% coinsurance(authorization and referral required)
Outpatient substance use, group session	20% coinsurance(authorization and referral required)
Opioid treatment program	$0 copay(authorization and referral required)
Ambulance and transportation
Ground ambulance	$150 copay(authorization required)
Air ambulance	20% coinsurance(authorization required)
Transportation to plan-approved locations	Not covered
Medical equipment and supplies
Durable medical equipment (e.g. wheelchairs, oxygen)	20% coinsurance(authorization required)
Prosthetics (e.g. braces, artificial limbs)	20% coinsurance(authorization required)
Medical supplies	$0 copay(authorization required)
Diabetes supplies	$0 copay(authorization required)
Diabetic therapeutic shoes or inserts	$0 copay(authorization required)
Chiropractic, acupuncture and foot care
Chiropractic (Medicare-covered)	$0 copay(authorization and referral required)
Routine chiropractic care	Not covered
Acupuncture	Not covered
Foot exams and treatment (Medicare-covered)	$5 copay(authorization and referral required)
Routine foot care	Not covered
Dental?
Medicare-covered dental services	$0 copay
Oral exams	Not covered
Cleanings	Not covered
Fluoride treatment	Not covered
Dental x-rays	Not covered
Other diagnostic dental services	Not covered
Other preventive dental services	Not covered
Restorative services (fillings, crowns)	Not covered
Endodontics (root canals)	Not covered
Periodontics (gum disease)	Not covered
Dentures and other removable prosthodontics	Not covered
Maxillofacial prosthetics	Not covered
Implants	Not covered
Bridges and other fixed prosthodontics	Not covered
Oral and maxillofacial surgery	Not covered
Orthodontics	Not covered
Adjunctive general services	Not covered
Vision?
Eye exam (Medicare-covered)	$0 copay
Routine eye exam	Not covered
Eyewear after cataract surgery (Medicare-covered)	$0 copay
Contact lenses	Not covered
Eyeglasses (frames and lenses)	Not covered
Eyeglass lenses	Not covered
Eyeglass frames	Not covered
Eyewear upgrades	Not covered
Hearing?
Hearing exam (Medicare-covered)	$0 copay(authorization and referral required)
Routine hearing exam	Not covered
Hearing aid fitting and evaluation	Not covered
Hearing aids (all types)	Not covered
Hearing aids, inner ear	Not covered
Hearing aids, outer ear	Not covered
Hearing aids, over the ear	Not covered
Medicare Part B drugs
Part B insulin	$0 copay(authorization required)
Chemotherapy and radiation drugs	0%–20% coinsurance(authorization required)
Other Part B drugs	0%–20% coinsurance(authorization required)
Other extra benefits?
Over-the-counter (OTC) allowance	Not covered
Meals after a hospital stay or for a chronic condition	Not covered
Fitness benefit	Not covered
Health education	Not covered
Nutritional / dietary benefit	Not covered
Extra smoking and tobacco cessation counseling	Not covered
Enhanced disease management	Not covered
Telemonitoring	Not covered
Remote access technologies (web/phone, nurse line)	Not covered
Home and bathroom safety devices	Not covered
Counseling services	Not covered
In-home safety assessment	Not covered
Personal emergency response system (PERS)	Not covered
Medical nutrition therapy	Not covered
Post-discharge in-home medication reconciliation	Not covered
Re-admission prevention	Not covered
Wigs for hair loss from chemotherapy	Not covered
Weight management programs	Not covered
Alternative therapies	Not covered
Therapeutic massage	Not covered
Adult day health services	Not covered
Home-based palliative care	Not covered
In-home support services	Not covered
Support for caregivers	Not covered

In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.

Star rating measures

Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H5496 shares it.

Benefits in plain text

Imperial Courage Plan (HMO) (H5496-016-0) is a 2027 HMO Medicare Advantage health plan without drug coverage offered by Imperial Health Plan of California, Inc., available to residents of Sutter County, CA.

The monthly premium is $0.00.

The plan reduces the member's Medicare Part B premium by $85.00 a month (a "giveback"); the Part B premium itself must still be paid.

There is no in-network deductible for health services.

Its in-network out-of-pocket maximum is $2,999.00.

CMS gives the plan's contract (H5496) an overall rating of 4 out of 5 stars.

Email a copy of the plan benefit details

Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.