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DEVOTED C-SNP PLUS 003 HI (HMO 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.
$42.40
Monthly Premium
DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) is a HMO C-SNP plan offered by Devoted Health
Plan ID: H5397-003
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 PLUS 003 HI (HMO C-SNP) - H5397-003 by Devoted Health as well as other Medicare Advantage plans available in your area.
$42.40
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $615 |
| Out of Pocket Max |
In-Network: $9250 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 | In-Network: Doctor Specialty Visit: Coinsurance for Physician Specialist Office Visit $30% Prior Authorization Required for Doctor Specialty Visit Cost share applies to wound care services, facet injections, cortisol injections, and specialist services. |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $2230 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 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $115 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0 Copayment for Worldwide Emergency Transportation (Ground) $0 Maximum Plan Benefit of $25,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Coinsurance for Ground Ambulance Services $0% to $35% Cost share applies per trip. Min cost share for facility to facility transfers. Max cost share for all other ambulance services. Air Ambulance: Coinsurance for Air Ambulance Services $35% Prior Authorization Required for Air Ambulance Cost share applies per trip. |
Health Care Services and Medical Supplies
DEVOTED C-SNP PLUS 003 HI (HMO 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 | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 |
| 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 35% Coinsurance for Medicare-covered Lab Services 35% Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Cost share varies based on site of service:PCPs office: No cost share for EKGs/EEGs/ECGs, no cost share all other. Specialist office: No cost share for EKGs/EEGs/ECGs, 35% coinsurance all other. Freestanding facility: 35% coinsurance for EKGs/EEGs/ECGs, 35% coinsurance all other. Outpatient hospital: 35% coinsurance for EKGs/EEGs/ECGs, 35% coinsurance all other. No cost share for home sleep studies. No cost share for remote patient monitoring services. Outpatient Diag/Therapeutic Rad Services: Coinsurance for Medicare-covered Diagnostic Radiological Services 35% Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Coinsurance for Medicare-covered X-Ray Services 35% |
| 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 $2080 Prior Authorization Required for Psychiatric Hospital Services |
| Mental Health Outpatient Care | In-Network: Outpatient 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 0% to 35% Prior Authorization Required for Outpatient Hospital Services The min cost share applies to diagnostic colonoscopies, the max cost share applies to all other outpatient hospital services. Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 35% Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Coinsurance for Ambulatory Surgical Center Services 0% to 35% Prior Authorization Required for Ambulatory Surgical Center Services The min cost share applies to diagnostic colonoscopies, the max cost share applies to all other ASC services. |
| Outpatient Substance Abuse Care | 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 | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
|
| Podiatry Services | In-Network: Podiatry Services: Coinsurance for Medicare-Covered Podiatry Services 30% Copayment for Routine Foot Care $0
|
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $218 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 | Medicare Covered Preventive Dental: Coinsurance for Office Visit 30% Prior Authorization Required for Medicare Covered Preventive Dental Non-Medicare Covered Dental Services: This plan has a Dental and Alternative Therapy Allowance with Partial Comprehensive Dental Costshare: You have a $4,000 yearly allowance toward preventive dental, comprehensive dental, therapeutic massage, routine acupuncture, and/or naturopath services combined. You can see any licensed provider in the United States. You will pay the costs yourself at first and then submit a request for reimbursement to Devoted. For dentures, crowns, root canals, bridges, therapeutic massage, routine acupuncture, and naturopath services a 50% coinsurance applies, with reimbursement up to the $4,000 yearly allowance. For all other covered services, you will receive 100% reimbursement up to the $4,000 yearly allowance. Cosmetic procedures, dental implants, elective procedures, herbs, homeopathic remedies, medications and nutritional supplements, vitamins, and/or vitamin injections are not covered. Non-Medicare Covered Preventive Dental: Maximum dental + alternative therapy allowance of $4,000 every year
Maximum dental + alternative therapy allowance of $4,000 every year
|
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Coinsurance for Medicare Covered Benefits 0% to 35% Copayment for Routine Eye Exams $0
The min cost share applies to diabetic retinopathy exams. The max cost share applies to other Medicare-covered eye exams. Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Copayment for Eyeglasses (lenses and frames) $0 Copayment for Eyeglass Lenses $0 Copayment for Eyeglass Frames $0 Copayment for Upgrades $0 Maximum Plan Benefit of $300 every year |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 35% Copayment for Routine Hearing Exams $0
Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $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 | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $615 (excludes Tiers 6) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $615 (excludes Tiers 6) |
| Select Care Drugs |
|
| Annual Drug Deductible | $615 (excludes Tiers 6) |
| Select Care Drugs |
|
| Annual Drug Deductible | $615 (excludes Tiers 6) |
| Select Care Drugs |
|