DEVOTED DUAL 011 OH (HMO D-SNP)
H2697-011 • 2026 • Ross County, OH
DEVOTED DUAL 011 OH (HMO D-SNP) H2697-011 • 2026 • Ross County, OH
DEVOTED DUAL 011 OH is a Medicare Dual-Eligible plan offered by Devoted Health for the 2026 plan year. It is identified by CMS Plan ID H2697-011 and serves individuals who meet defined eligibility criteria.
DEVOTED DUAL 011 OH Overview
Plan Overview for H2697-011-0 | |
|---|---|
| CMS Plan ID: | H2697-011-0 |
| Plan Type: | HMO D-SNP |
| Plan Year: | 2026 |
| Monthly Premium: | $31.40 Plus your Medicare Part B premium. |
| Medical Deductible: | $0.00 |
| Maximum Out-of-Pocket: | $4300.00 (In-Network) |
| Part B Give Back: | Not offered |
| Prescription Drug Coverage: | Enhanced, $615.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Service Area: | Ross County, OH |
| Enrollment (Nationwide) | 1,604 beneficiaries |
| Enrollment (CMS – Local) | 0 beneficiaries in Ross County |
| Provided By: | Devoted Health |
Plan Overview and Eligibility
DEVOTED DUAL 011 OH is a Medicare D-SNP plan for people who qualify for both Medicare and Medicaid.
- To enroll, you must have Medicare Part A and Part B, live in the plan’s service area, and qualify for Medicaid.
- Prescription drug coverage (Medicare Part D) is included. The annual Part D deductible is $615.00.
- Cost-sharing and benefits may be coordinated with Medicaid, depending on your eligibility level.
- People who qualify for Medicare Extra Help may receive additional assistance with prescription drug costs.
DEVOTED DUAL 011 OH uses a Health Maintenance Organization (HMO) network for delivery of care. As an HMO member, you generally receive services through the plan’s network of providers, with referrals typically required to see specialists. Emergency care and out-of-area dialysis are covered even outside the network.
Covered Services and Cost Structure
This section outlines in-network costs for primary care and specialist office visits, along with related preventive services.
| Covered Service | In-Network Cost |
|---|---|
| Primary: | In-network: $0 copay |
| Specialist: | In-network: $0 or $35 copay |
This section outlines in-network costs for preventive and wellness services included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Annual wellness exam: | In-network: $0 copay |
| Telehealth benefit: | In-network: $0 or $0-$45 copay |
| Routine chiropractic: | Not covered |
| Fitness benefits: | In-network: $0 copay |
| Health education: | In-network: $0 copay |
| Counseling services: | Not covered |
| Over-the-counter drug benefits: | In-network: $0 copay |
| Health transportation (non-emergency): | Not covered |
This section outlines in-network costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Covered Service | In-Network Cost |
|---|---|
| Diagnostic radiology services: | In-network: $0 or $0-$200 copay |
| Lab services: | In-network: $0 or $0-$20 copay |
| Outpatient x-rays: | In-network: $0 or $0-$100 copay |
| Diagnostic tests and procedures: | In-network: $0 or $0-$100 copay |
This section outlines in-network costs for emergency services, urgent care, ambulance transportation, inpatient hospital stays, and skilled nursing facility care.
| Covered Service | In-Network Cost |
|---|---|
| Emergency room care: | $0 or $130 copay |
| Worldwide emergency care: | $130 copay |
| Urgent care: | $0 or $0-$45 copay |
| Inpatient hospital care: | Tier 1 | $0 or $300 per day for days 1-6 | $0 per day for days 7-90 | $0 per stay |
| Skilled Nursing Facility: | Tier 1 | $0 per day for days 1-20 | $0 or $218 per day for days 21-100 |
| Ground ambulance: | In-network: $0 or $0-$315 copay |
This section outlines in-network costs for mental health services, including outpatient therapy and inpatient psychiatric care.
| Covered Service | In-Network Cost |
|---|---|
| Outpatient individual therapy: | In-network: $0 or $35 copay |
| Outpatient group therapy: | In-network: $0 or $35 copay |
| Inpatient psychiatric hospital care: | Tier 1 | $0 or $300 per day for days 1-6 | $0 per day for days 7-90 | $0 per stay |
This section outlines in-network costs for rehabilitation services, including physical therapy, speech and language therapy, and occupational therapy.
| Covered Service | In-Network Cost |
|---|---|
| Physical therapy and speech and language therapy: | In-network: $0 or $35-$50 copay |
| Occupational therapy: | In-network: $0 or $35-$50 copay |
This section outlines in-network costs for medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Covered Service | In-Network Cost |
|---|---|
| Diabetes supplies: | In-network: 0% or 0%-30% coinsurance |
| Durable medical equipment: | In-network: 0% or 20%-30% coinsurance |
| Prosthetics: | In-network: 0% or 0%-20% coinsurance |
This section outlines in-network cost sharing for chemotherapy and other Medicare Part B-covered drugs.
| Covered Service | In-Network Cost |
|---|---|
| Chemotherapy: | In-network: 0% or 0%-20% coinsurance |
| Other Part B drugs (Medicare-covered): | In-network: 0% or 0%-20% coinsurance |
This section outlines in-network cost sharing for dental services, including preventive care, exams, x-rays, cleanings, and comprehensive dental procedures.
| Covered Service | In-Network Cost |
|---|---|
| Oral exam: | In-network: $0 copay |
| Dental x-rays: | In-network: $0 copay |
| Cleaning: | In-network: $0 copay |
| Periodontics: | In-network: $0 copay |
| Endodontics: | In-network: $0 copay |
| Restorative services: | In-network: $0 copay |
| Implant services: | In-network: $0 copay |
| Orthodontics: | In-network: $0 copay |
| Oral/Maxillofacial surgery: | In-network: $0 copay |
This section outlines in-network cost sharing for vision services, including eye exams, eyeglasses, and contact lenses.
| Covered Service | In-Network Cost |
|---|---|
| Routine eye exam: | In-network: $0 copay |
| Contact lenses: | In-network: $0 copay |
| Eyeglass frames only: | In-network: $0 copay |
| Eyeglass lenses only: | In-network: $0 copay |
| Eyeglasses (frames & lenses): | In-network: $0 copay |
| Upgrades: | In-network: $0 copay |
This section outlines in-network cost sharing for hearing-related services, including exams, fittings, and hearing aids.
| Covered Service | In-Network Cost |
|---|---|
| Hearing exam: | In-network: $0 copay |
| Fitting/evaluation: | In-network: $0 copay |
| Prescription hearing aids: | In-network: $0-$299 copay |
| OTC hearing aids: | Not covered |
This section outlines in-network cost sharing for additional and special needs services that may be included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Adult day health services: | Not covered |
| Home-based palliative care: | Not covered |
| Personal emergency response system: | Not covered |
| Weight management programs: | In-network: $0 copay |
| Wigs for chemotherapy-related hair loss: | Not covered |
| Alternative therapies: | In-network: $0 copay |
| Massage therapy: | Not covered |
| Home/bathroom safety devices: | In-network: $0 copay |
Prescription Drug Plan Costs & Benefits
Prescription Drug Plan Premium
The following table outlines the prescription drug plan premium details of this plan.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $31.40 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $31.40 |
| Low Income Premium Subsidy: | $31.38 |
| Low Income Premium Subsidy CMS Pays: | $31.40 |
| Low Income Subsidy Premium: | $0.00 |
For more information about the Low Income Subsidy, refer to the Social Security Extra Help page.
Drug Plan Deductible
The prescription drug annual deductible with this plan is $615.00. This is the amount you must pay at the pharmacy before Devoted Health begins paying its share.
Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and drug plan deductible, DEVOTED DUAL 011 OH has costs that you must pay out-of-pocket when you pick up your prescriptions. The following table details those costs by formulary tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | 25% coinsurance | Coming soon |
| Generic | 25% coinsurance | Coming soon |
| Preferred Brand | 25% coinsurance | Coming soon |
| Non-Preferred Drug | 25% coinsurance | Coming soon |
| Specialty Tier | 25% coinsurance | Coming soon |
| Select Care Drugs | $0.00 copay | Coming soon |
| *Deductible does not apply. | ||
Quality Ratings (CMS)
Medicare evaluates plan quality using a star rating system developed by the Centers for Medicare & Medicaid Services (CMS). Ratings are based on measures such as health outcomes, member experience, and customer service, and are reported on a 1 to 5 star scale, with higher ratings indicating stronger overall performance.
CMS Star Ratings for Plan H2697-011-0 – 2026
| CMS Measure | Star Rating (out of 5) |
|---|---|
| 2026 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for Devoted Health
| Contact Type | Details |
|---|---|
| Website: | Devoted Health Plan Page |
| New Members: | 1-844-978-2770 |
| Existing Members: | 1-800-338-6833 |
| Plan Address: | Devoted Health | PO Box 211037 | Eagan, MN 55121 |
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at medicare.gov.
- CMS.gov, Landscape Source Files — Last accessed May 2, 2026
- CMS.gov, Medicare Part C & D Performance — Last accessed May 2, 2026
- CMS.gov, Plan Benefits Package — Last accessed May 2, 2026
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County — Last accessed May 2, 2026
Data sources and methodology documentation.
- Devoted Health (official source), http://www.Devoted.com — Last accessed April 30, 2026
- CMS.gov, "Dual Eligible Special Needs Plans (D-SNPs)" — Last accessed April 28, 2026
- Medicare.gov, "Understanding Medicare Advantage Plans" — Last accessed April 28, 2026
- AARP.org, "The Big Choice: Original Medicare vs. Medicare Advantage" — Last accessed April 28, 2026
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