Devoted DUAL Ohio (HMO D-SNP)
Devoted DUAL Ohio (HMO D-SNP) H2697-011 Plan Details
Devoted DUAL Ohio (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H2697-011
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.
$0.00
Monthly Premium
Devoted DUAL Ohio (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H2697-011
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.
Ohio Counties Served
Clark
Champaign
Greene
Shelby
Hamilton
Butler
Preble
Warren
Miami
Montgomery
Clermont
Brown
Darke
Logan
Crawford
Hardin
Wyandot
Seneca
Erie
Hancock
Auglaize
Wood
Sandusky
Ottawa
Lucas
Fulton
Defiance
Henry
Paulding
Putnam
Huron
Mercer
Allen
Van Wert
Hocking
Vinton
Ross
Adams
Clinton
Highland
Delaware
Union
Franklin
Madison
Pickaway
Licking
Morrow
Coshocton
Holmes
Richland
Fairfield
Perry
Fayette
Marion
Tuscarawas
Columbiana
Guernsey
Carroll
Geauga
Cuyahoga
Medina
Lorain
Lake
Summit
Trumbull
Portage
Wayne
Stark
Ashland
Mahoning
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $4500 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| 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 $0 or $35 |
| Inpatient Hospital Care | Inpatient Hospital Coverage:
|
| Urgent Care | Copayment for Urgent Care $0 to $45 $0 copay for urgently needed services received by a PCP.$45 copay for urgently needed services received from an urgent care center. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 |
| Emergency Room Visit | Copayment for Emergency Care $0 or $125 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 $125 Copayment for Worldwide Emergency Transportation $300 |
| Ambulance Transportation | Ground Ambulance $300 PA may be required (Medicaid covered: $0) Air or Water Ambulance 20% PA may be required (Medicaid covered: $0) Facility to Facility Transfer Member will not be responsible for additional ground ambulance copays for facility to facility transfers. |
Health Care Services and Medical Supplies
Devoted DUAL Ohio (HMO D-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 | Chiropractic Services - Medicare Covered Copayment $20 (Medicaid covered: $0) Chiropractic Services - Routine Visits Copayment Not covered |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | Copayment for Medicare-covered Diabetic Supplies $0 PA may be required Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 PA may be required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 50% Prior Authorization Required for Durable Medical Equipment Plan covers crutches with 20% coinsurance.The following DME has 50% coinsurance: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, Continuous Glucose Monitor (other than Plan's preferred CGM), and Home Infusion Therapy (HIT) drugs.$0 copay for the Plan's preferred Continuous Glucose Monitor.20% coinsurance for all other DME. Prior authorization required |
| 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 $100 Copayment for Medicare-covered Lab Services $0 to $20 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Copayment varies based on site of service:PCPs office: $0 copay for EKGs/EEGs/ECGs, $0 copay all other. Specialist office: $0 copay for EKGs/EEGs/ECGs, $45 copay all other. Freestanding facility: $45 copay for EKGs/EEGs/ECGs, $45 copay all other. Outpatient hospital: $100 copay for EKGs/EEGs/ECGs, $100 copay all other. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $200 Coinsurance for Medicare-covered Therapeutic Radiological Services 0% or 20% Copayment for Medicare-covered X-Ray Services $0 to $100 Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | 0 or $In-Network: Psychiatric Hospital Services: $300 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0 or $35 Copayment for Medicare-covered Group Sessions $0 or $35 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $400 Prior Authorization Required for Outpatient Hospital Services $0 copay for diagnostic colonoscopies, $400 copay for all other outpatient hospital services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0 or $300 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $300 Prior Authorization Required for Ambulatory Surgical Center Services $0 copay for diagnostic colonoscopies, $300 copay for all other ASC services. Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0 or $35 Copayment for Medicare-covered Group Sessions $0 or $35 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0 or $35 Copayment for Routine Foot Care $35
|
| Skilled Nursing Facility Care | 0 or $In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | This plan has a: Dental/Eyewear Card. Copayment for Medicare Covered Dental Services: $35 PA may be required (Medicaid covered: $0) Preventive & Comprehensive Dental Services: You have $500 per year towards Preventive Dental, Comprehensive Dental, and/or Eyewear combined. You can see any licensed dentist or visit any eyewear retailer. The $500 will be preloaded onto a debit card. You can use your card at any dental or eyewear provider who accepts MasterCard. Cosmetic procedures, dental implants, and/or elective procedures are not eligible. Please see Summary of Benefits and Evidence of Coverage for more benefit information. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 or $35 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $500 every year. Allowance may be combined with comprehensive dental benefits. Please see Summary of Benefits and Evidence of Coverage for more benefit information. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0 or $35 Copayment for Routine Hearing Exams $0
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 |
