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DEVOTED C-SNP CHOICE PLUS 031 TN (PPO C-SNP) - H7028-031-000
$0.00
Monthly Premium
DEVOTED C-SNP CHOICE PLUS 031 TN (PPO C-SNP) is a PPO C-SNP Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H7028-031-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Tennessee Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other additional benefits Original Medicare doesn’t cover.
Learn more about Tennessee Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $650.00 |
| Out-of-pocket maximum | $9,850.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit 30% |
| 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 031 TN (PPO C-SNP) covers a range of additional benefits. Learn more about DEVOTED C-SNP CHOICE PLUS 031 TN (PPO C-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 30% |
| 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 | Out-of-Network: Diagnostic Procedures/Tests Services: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 0% to 50% Coinsurance for Medicare-covered Lab Services 0% to 50% Coinsurance for Medicare-covered Diagnostic Radiological Services 40% to 50% Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Coinsurance for Medicare-covered Outpatient X-Ray Services 40% 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. |
| 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 | Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 40% |
| 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 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 | 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 items | Over-the-Counter Items (OTC): $50 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
|
| Skilled Nursing Facility (SNF) care | Out-of-Network: Skilled Nursing Facility Services: Coinsurance for Skilled Nursing Facility per Stay 40% |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Medicare Covered Preventive Dental: Coinsurance for office visit 30% Prior Authorization may be required. Non-Medicare Covered Dental Services: Devoted Health will pay as much as $2,500 per year for covered dental services. You pay $0 towards all covered dental services until you reach your plan's dollar limit. For any services received after you reach your plan's dollar limit, you'll pay the full cost. Covered dental services are limited to specific dental codes as listed in your Evidence of Coverage, and include, but are not limited to: periodic oral exams, dental evaluations, cleanings, X-rays, fillings, deep cleanings, extractions, dentures, root canals, crowns, and bridges. Cosmetic procedures, dental implants, and/or elective procedures are not covered. See your Evidence of Coverage for a full list of covered services and coverage limitations. Non-Medicare Covered Preventive Dental: Maximum plan benefit of $2,500 per year. Please see Evidence of Coverage for dental code restrictions and frequency limitations. Copayment for Oral exams $0 Copayment for Dental x-rays $0 Copayment for Prophylaxis (cleanings) $0 Copayment for Fluoride treatment $0 Non-Medicare Covered Comprehensive Dental: Maximum plan benefit of $2,500 per year. Please see Evidence of Coverage for dental code restrictions and frequency limitations. Copayment for Restorative services (e.g. fillings, crowns) $0 Copayment for Endodontics (e.g. root canal) $0 Copayment for Periodontics (e.g. scaling, root planing) $0 Copayment for Prosthodontics, removable (e.g. dentures) $0 Copayment for Prosthodontics, fixed (e.g. bridges) $0 Copayment for Maxillofacial surgery (e.g. extractions) $0 Copayment for Adjunctive general services $0 |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Out-of-Network: Medicare-Covered Vision Care: Coinsurance for Medicare-Covered Diagnostic Eye Exams 50% Copayment for Diabetic Retinopathy Exams $0 Routine Vision Care: Copayment for Routine Eye Exam $0
|
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | Out-of-Network: Hearing Exams: Coinsurance for Medicare-covered Hearing Care 50% Copayment for Routine Hearing Exam $35
Hearing Aids: Coinsurance per aid 90%
|
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Preventive Care: Our plan covers many preventive services at no cost, including:
|
When reviewing Tennessee Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Tennessee that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Tennessee Counties Served
- Anderson
- Benton
- Bledsoe
- Blount
- Bradley
- Campbell
- Cannon
- Carroll
- Carter
- Cheatham
- Claiborne
- Clay
- Cocke
- Cumberland
- Davidson
- Dekalb
- Fayette
- Fentress
- Giles
- Grainger
- Grundy
- Hamblen
- Hamilton
- Hancock
- Hardeman
- Haywood
- Hickman
- Houston
- Humphreys
- Jackson
- Jefferson
- Johnson
- Knox
- Lake
- Lauderdale
- Lawrence
- Lewis
- Lincoln
- Loudon
- Macon
- Marion
- Marshall
- Meigs
- Monroe
- Moore
- Morgan
- Obion
- Overton
- Perry
- Pickett
- Polk
- Rhea
- Roane
- Robertson
- Scott
- Sequatchie
- Sevier
- Shelby
- Smith
- Stewart
- Sullivan
- Sumner
- Trousdale
- Unicoi
- Union
- Van Buren
- Warren
- Washington
- Wayne
- White
- Williamson
- Wilson
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.