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DEVOTED C-SNP CHOICE PLUS 003 NH (PPO C-SNP)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
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Monthly Premium
DEVOTED C-SNP CHOICE PLUS 003 NH (PPO C-SNP) is a PPO C-SNP plan offered by Devoted Health
Plan ID: H7191-003
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as DEVOTED C-SNP CHOICE PLUS 003 NH (PPO C-SNP) - H7191-003 by Devoted Health as well as other Medicare Advantage plans available in your area.
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Monthly Premium
New Hampshire Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $650 |
| Out of Pocket Max | In-Network: $9850 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2100 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty Doctor Visit | Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit $40% Cost share applies to wound care services and specialist services. |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $2241 Prior Authorization Required for Acute Hospital Services |
| Urgent Care | Urgent Care: Coinsurance for Urgent Care 0% to 20% The min cost share applies to urgently needed services received by a PCP. The max cost share applies to urgently needed services received from an urgent care center. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 Maximum Plan Benefit of $25,000 per lifetime. Please see Evidence of Coverage for full benefit details. |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $115 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0 Copayment for Worldwide Emergency Transportation $0 Maximum Plan Benefit of $25,000 per lifetime. Please see Evidence of Coverage for full benefit details. |
| Ambulance Transportation | Ground Ambulance: Coinsurance for Ground Ambulance Services $50% Air Ambulance: Coinsurance for Air Ambulance Services $50% Prior Authorization Required for Air Ambulance Cost share applies per trip. |
Health Care Services and Medical Supplies
DEVOTED C-SNP CHOICE PLUS 003 NH (PPO C-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 30% In-Network: Chiropractic Services: Coinsurance for Medicare-covered Chiropractic Services 30% Prior Authorization Required for Chiropractic Services |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0
Dexcom Continuous Glucose Monitors (CGMs) and Supplies (Preferred): Copayment when obtained at a retail pharmacy $0 Coinsurance when obtained through a Durable Medical Equipment provider 20% Non-Preferred CGMs and Supplies: Copayment when obtained at a retail pharmacy $0
Please see the Evidence of Coverage for full glucose monitor benefit information. |
| Durable Medical Equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 0% to 50% Coinsurance for Medicare-covered Lab Services 0% to 50% Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services The min cost share applies to home sleep studies and other diagnostic tests at a PCP office or in the home. The max cost share applies to EKGs/EEGs/ECGs at all sites of service and all other diagnostic tests at a specialist office, freestanding facility, or an outpatient hospital. Outpatient Diag/Therapeutic Rad Services: Coinsurance for Medicare-covered Diagnostic Radiological Services 40% to 50% Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Coinsurance for Medicare-covered X-Ray Services 40% |
| Home Health Care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $2091 Prior Authorization Required for Psychiatric Hospital Services |
| Mental Health Outpatient Care | Out-of-Network: Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 30% Coinsurance for Medicare Covered Group Sessions 30% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 15% to 50% Prior Authorization Required for Outpatient Hospital Services The min cost share applies to screening colonoscopies that become diagnostic. The max cost share applies to diagnostic colonoscopies and to all other outpatient hospital services. Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 50% Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Coinsurance for Ambulatory Surgical Center Services 15% to 50% Prior Authorization Required for Ambulatory Surgical Center Services The min cost share applies to screening colonoscopies that become diagnostic. The max cost share applies to diagnostic colonoscopies and all other ASC services. |
| Outpatient Substance Abuse Care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 30% Coinsurance for Medicare Covered Group Sessions 30% In-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare-covered Individual Sessions 30% Coinsurance for Medicare-covered Group Sessions 30% Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter (OTC) Items | Over-the-Counter Items (OTC): $48 per quarter to use toward the purchase of eligible over-the-counter (OTC) items at participating locations. You get the most out of your OTC benefits when you shop at participating locations. If you purchase items at non-participating stores, you will be responsible for a 90% coinsurance. Please see Evidence of Coverage for full benefit details. |
| Podiatry Services | In-Network: Podiatry Services: Coinsurance for Medicare-Covered Podiatry Services 30% Copayment for Routine Foot Care $0
Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $221 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | Out-of-Network: Medicare Covered Preventive Dental: Coinsurance for office visit 40% Non-Medicare Covered Dental Services: If you choose to see an out-of-network dentist, you will be responsible for paying the difference between the rate we pay the dentist and the rate your dental provider charges, even if you have not yet reached your plan's dollar limit. Please see Evidence of Coverage for full benefit details. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Medicare-Covered Vision Care: Coinsurance for Medicare-Covered Diagnostic Eye Exams 50% Copayment for Diabetic Retinopathy Exams $0 Prior authorization may be required. Routine Vision Care: Copayment for Routine Eye Exam $0
Eyewear: Up to $200 each year for eyeglasses and/or contacts You can visit any eyewear provider, in-network or out-of-network. Please see the Evidence of Coverage for full benefit details. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Coinsurance for Medicare-covered Hearing Care 50% Copayment for Routine Hearing Exam $0
Prior Authorization may be required. Hearing Aids: Copayment per aid $399 to $699
|
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | Preventive Care: Our plan covers many preventive services at no cost, including:
|
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