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DEVOTED C-SNP ENHANCED 010 VA (HMO C-SNP) - H6994-010-000
$0.00
Monthly Premium
DEVOTED C-SNP ENHANCED 010 VA (HMO C-SNP) is a HMO C-SNP Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H6994-010-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Virginia 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 Virginia 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 | $461.00 |
| Out-of-pocket maximum | $6,200.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30 Prior Authorization Required for Doctor Specialty Visit Cost share applies to wound care services and specialist services. |
| Inpatient hospital care | In-Network: Acute Hospital Services: $395 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 to $45 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 $130 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 $130 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $130 Copayment for Worldwide Emergency Transportation $315 Maximum Plan Benefit of $25,000 per lifetime. Please see Evidence of Coverage for full benefit details. |
| Ambulance transportation | Ground Ambulance: Copayment for Ground Ambulance Services $0 to $315 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 20% Prior Authorization Required for Air Ambulance Cost share applies per trip. |
Health Care Services and Medical Supplies
DEVOTED C-SNP ENHANCED 010 VA (HMO C-SNP) covers a range of additional benefits. Learn more about DEVOTED C-SNP ENHANCED 010 VA (HMO C-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| 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: 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 50% Non-Preferred CGMs and Supplies: Coinsurance when obtained at a retail pharmacy 50%
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% to 50% Prior Authorization Required for Durable Medical Equipment The max coinsurance applies to the following DME: Medicare-covered ventilator, Bone growth stimulator, Portable oxygen concentrator, Bariatric equipment, Specialty beds, Custom or specialty wheelchairs and scooters, Seat lifts, Specialty brand items, High Frequency Chest Compression Vests, Pain Infusion Pump, and Home Infusion Therapy (HIT) drugs. The min coinsurance applies to all other DME |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $95 Copayment for Medicare-covered Lab Services $0 to $30 Coinsurance for Genetic Testing 20% 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 mid cost share applies to EKGs/EEGs/ECGs at a PCP, specialist office, or freestanding facility and all other diagnostic tests at a specialist office or freestanding facility. The max cost share applies to EKGs/EEGs/ECGs and all other diagnostic tests at an outpatient hospital. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $25 to $300 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $75 |
| 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: $395 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $30 Copayment for Medicare-covered Group Sessions $30 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $495 Prior Authorization Required for Outpatient Hospital Services The min cost share applies to diagnostic colonoscopies and screening colonoscopies that become diagnostic. The max cost share applies to all other outpatient hospital services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $395 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $395 Prior Authorization Required for Ambulatory Surgical Center Services The min cost share applies to diagnostic colonoscopies and screening colonoscopies that become diagnostic. The max cost share applies to all other ASC services. |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $30 Copayment 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. Please see Evidence of Coverage for full benefit details. |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $30 Copayment for Routine Foot Care $30
|
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $10 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, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Medicare Covered Preventive Dental: Copayment 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 | In-Network: Medicare-Covered Vision Care: Copayment for Medicare-Covered Diagnostic Eye Exams $30 Copayment for Diabetic Retinopathy Exams $0 Prior authorization may be required. Routine Vision Care: Copayment for Routine Eye Exam $0
Eyewear: Up to $300 each year for eyeglasses and/or contacts. You must use our designated vendor for this benefit. Please see the Evidence of Coverage for full benefit details. |
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 | In-Network: Hearing Exams: Copayment for Medicare-covered Hearing Care $30 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, 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 Virginia 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 Virginia 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 |
Virginia Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.