Devoted RESTORE PLUS Tennessee - D (HMO C-SNP) By Devoted Health
Devoted RESTORE PLUS Tennessee - D (HMO C-SNP) H7605 006 0 is a 2023 Medicare Advantage Special Needs Plan plan by Devoted Health. This plan from Devoted Health works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Devoted Health and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage.
Devoted RESTORE PLUS Tennessee - D (HMO C-SNP) H7605-006 is a Chronic Condition SNP (C-SNP). A Chronic Condition SNP is for beneficiaries with the
following severe or disabling chronic conditions: HIV/AIDS. If you have Medicare and you develop certain severe or disabling conditions you can join a Medicare SNP designed to serve people with those conditions at any time.
The Devoted RESTORE PLUS Tennessee - D (HMO C-SNP) H7605-006 is available to residents to
Medicare eligible seniors in Tennessee.
All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage.
Devoted RESTORE PLUS Tennessee - D (HMO C-SNP) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the plan.
How much does Devoted RESTORE PLUS Tennessee - D (HMO C-SNP) cost?
Part-C Premium
A monthly premium is the fee you pay to the plan in exchange for coverage. Devoted Health charges a $0 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
Part-D Deductible and Premium
An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Devoted RESTORE PLUS Tennessee - D (HMO C-SNP) has a monthly drug premium of $35.20 and a $505.00 drug deductible. This Devoted Health plan offers a $35.20 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by Devoted Health above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $35.20. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.
Devoted Health Gap Coverage
In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Devoted Health plan does offer additional coverage through the gap.
Extra Help Premium Assistance
The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Devoted RESTORE PLUS Tennessee - D (HMO C-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $8.80 for 75% low-income subsidy $17.60 for 50% and $26.40 for 25%.
Full Assistance Premium:
$0
75% Assistance Premium:
$8.80
50% Assistance Premium:
$17.60
25% Assistance Premium:
$26.40
H7605-006 Formulary and Drug Coverage
Devoted RESTORE PLUS Tennessee - D (HMO C-SNP) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers.
By reviewing different Medicare Drug formularies, you can pick a Medicare Special Needs Plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.
The benefit information provided is a summary of what Devoted RESTORE PLUS Tennessee - D (HMO C-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Devoted Health helps
get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.
$0 per day for days 1 through 20 $196 per day for days 21 through 52 $0 per day for days 53 through 100
Occupational therapy visit
Rehabilitation services
$15 copay
Physical therapy and speech and language therapy visit
Rehabilitation services
$15 copay
Cleaning
Preventive dental
$0 copay
Dental x-ray(s)
Preventive dental
$0 copay
Fluoride treatment
Preventive dental
$0 copay
Oral exam
Preventive dental
$0 copay
Preventive care
$0 copay
Outpatient hospital coverage
$0-225 copay per visit
In-Network Other health plan deductibles?
No
Optional supplemental benefits
No
Inpatient hospital - psychiatric
Mental health services
$265 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit
Mental health services
$15 copay
Outpatient group therapy visit with a psychiatrist
Mental health services
$15 copay
Outpatient individual therapy visit
Mental health services
$15 copay
Outpatient individual therapy visit with a psychiatrist
Mental health services
$15 copay
Chemotherapy
Medicare Part B drugs
20% coinsurance
Other Part B drugs
Medicare Part B drugs
0-20% coinsurance
Diabetes supplies
Medical equipment/supplies
$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)
Medical equipment/supplies
0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)
Medical equipment/supplies
0-20% coinsurance per item
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$5,900 In-network
Inpatient hospital coverage
$265 per day for days 1 through 5 $0 per day for days 6 through 90
Fitting/evaluation
Hearing
$0 copay
Hearing aids
Hearing
$199-499 copay
Hearing exam
Hearing
$15 copay
Health plan deductible
$0
Ground ambulance
$300 copay
Foot exams and treatment
Foot care (podiatry services)
$15 copay
Routine foot care
Foot care (podiatry services)
$15 copay
Emergency
Emergency care/Urgent care
$95 copay per visit (always covered)
Urgent care
Emergency care/Urgent care
$0-40 copay per visit (always covered)
Primary
Doctor visits
$0 copay
Specialist
Doctor visits
$0-15 copay per visit
Diagnostic radiology services (e.g., MRI)
Diagnostic procedures/lab services/imaging
$0-100 copay
Diagnostic tests and procedures
Diagnostic procedures/lab services/imaging
$0-20 copay
Lab services
Diagnostic procedures/lab services/imaging
$0 copay
Outpatient x-rays
Diagnostic procedures/lab services/imaging
$0 copay
Diagnostic services
Comprehensive dental
$0 copay
Endodontics
Comprehensive dental
$0 copay
Extractions
Comprehensive dental
$0 copay
Non-routine services
Comprehensive dental
$0 copay
Periodontics
Comprehensive dental
$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services
Comprehensive dental
$0 copay
Restorative services
Comprehensive dental
$0 copay
In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
Yes, contact plan for further details
Coverage Area
(Click county or state to compare all available Advantage plans)
The availability of Medicare Special Need Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Devoted RESTORE PLUS Tennessee - D (HMO C-SNP) requires you to live in that plan’s service area. The service area is listed below:
Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.
Includes 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.
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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.
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