DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) Medicare Special Need Plan H5397-003 • 2027
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $990
- Maximum Out-of-Pocket
- $9850.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $461.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 278 beneficiaries
Introduction
DEVOTED C-SNP PLUS 003 HI, offered by Devoted Health, is a Medicare Advantage Chronic Condition Special Needs Plan (C-SNP) identified by CMS Plan ID H5397-003. The plan's Health Maintenance Organization (HMO) provider network serves its covered medical benefits, and the plan includes Medicare Part D prescription drug coverage. Its 2027 costs include a $0.00 monthly premium, $990 medical deductible, and $9850.00 in-network maximum out-of-pocket. The 2027 Part D prescription drug deductible is $461.00.
This plan has 278 beneficiaries enrolled across its service areas based on CMS enrollment data. To enroll, you must live within the plan's service area: See List.
Eligibility
DEVOTED C-SNP PLUS 003 HI is a Medicare C-SNP plan for individuals with specific chronic or disabling conditions.
- Special Needs Plan Type
- Chronic Condition Special Needs Plan (C-SNP)
- Medicare Requirement
- Must have Medicare Part A and Part B
- Special Needs Requirement
- This plan is for individuals with cardiovascular disorders, chronic heart failure, and/or diabetes mellitus.
- Service Area Requirement
- Must live in the plan's service area
- Prescription Drug Coverage
- Medicare Part D prescription drug coverage is included.
Plan Benefits
DEVOTED C-SNP PLUS 003 HI has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The tables below detail the most common in-network out-of-pocket expenses for plan H5397-003.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay | In-network: $0 copay |
| Specialist | In-network: 30% coinsurance | In-network: 30% coinsurance |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | In-network: $0 copay | In-network: $0 copay |
| Telehealth benefit | In-network: 0%-30% coinsurance | In-network: 0%-30% coinsurance |
| Routine chiropractic | Not covered | Not covered |
| Fitness benefits | Coming soon | In-network: $0 copay |
| Health education | In-network: $0 copay | In-network: $0 copay |
| Counseling services | Not covered | Not covered |
| Over-the-counter drug benefits | In-network: $0 copay | In-network: $0 copay |
| Health transportation (non-emergency) | Coming soon | Not covered |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: 40%-50% coinsurance | In-network: 35% coinsurance |
| Lab services | In-network: 0%-50% coinsurance | In-network: 35% coinsurance |
| Outpatient x-rays | In-network: 40% coinsurance | In-network: 35% coinsurance |
| Diagnostic tests and procedures | In-network: 0%-50% coinsurance | In-network: 0%-35% coinsurance |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $115 copay | $115 copay |
| Worldwide emergency care | Coming soon | $0 copay |
| Urgent care | 0%-20% coinsurance | 0%-20% coinsurance |
| Inpatient hospital care | Tier 1 $2,241 per stay |
Tier 1 $2,230 per stay |
| Skilled Nursing Facility | Tier 1 $0 per day for days 1-20 $221 per day for days 21-100 |
Tier 1 $0 per day for days 1-20 $218 per day for days 21-100 |
| Ground ambulance | In-network: 50% coinsurance | In-network: 0%-35% coinsurance |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: 30% coinsurance | In-network: 30% coinsurance |
| Outpatient group therapy | In-network: 30% coinsurance | In-network: 30% coinsurance |
| Inpatient psychiatric hospital care | Tier 1 $2,241 per stay |
Tier 1 $2,230 per stay |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: 30% coinsurance | In-network: 30% coinsurance |
| Occupational therapy | In-network: 30% coinsurance | In-network: 30% coinsurance |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: $0 copay | In-network: 20% coinsurance |
| Durable medical equipment | In-network: 20% coinsurance | In-network: 20% coinsurance |
| Prosthetics | In-network: 20% coinsurance | In-network: 0%-20% coinsurance |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance | In-network: 0%-20% coinsurance |
| Other Part B drugs (Medicare-covered) | In-network: 0%-20% coinsurance | In-network: 0%-20% coinsurance |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay | In-network: $0 copay |
| Dental x-rays | In-network: $0 copay | In-network: $0 copay |
| Cleaning | In-network: $0 copay | In-network: $0 copay |
| Periodontics | In-network: 50% coinsurance | In-network: $0 copay |
| Endodontics | In-network: 50% coinsurance | In-network: 0%-50% coinsurance |
| Restorative services | In-network: 50% coinsurance | In-network: 0%-50% coinsurance |
| Implant services | In-network: 50% coinsurance | Not covered |
| Orthodontics | Not covered | Not covered |
| Oral/Maxillofacial surgery | In-network: 50% coinsurance | In-network: $0 copay |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay | In-network: $0 copay |
| Contact lenses | In-network: $0 copay | In-network: $0 copay |
| Eyeglass frames only | In-network: $0 copay | In-network: $0 copay |
| Eyeglass lenses only | In-network: $0 copay | In-network: $0 copay |
| Eyeglasses (frames & lenses) | In-network: $0 copay | In-network: $0 copay |
| Upgrades | In-network: $0 copay | In-network: $0 copay |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay | In-network: $0 copay |
| Fitting/evaluation | In-network: $0 copay | In-network: $0 copay |
| Prescription hearing aids | In-network: $399-$699 copay | In-network: $399-$699 copay |
| OTC hearing aids | Not covered | Not covered |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Not covered |
| Home-based palliative care | Not covered | Not covered |
| Personal emergency response system | Coming soon | Not covered |
| Weight management programs | In-network: $0 copay | In-network: $0 copay |
| Wigs for chemotherapy-related hair loss | Coming soon | Not covered |
| Alternative therapies | In-network: 0%-50% coinsurance | In-network: 0%-50% coinsurance |
| Massage therapy | In-network: 50% coinsurance | In-network: 50% coinsurance |
| Home/bathroom safety devices | In-network: $0 copay | In-network: $0 copay |
Certain preventive services are covered 100% by DEVOTED C-SNP PLUS 003 HI as a Part B benefit.
Prescription Drug Coverage
DEVOTED C-SNP PLUS 003 HI includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | ($60.80) |
| Supplemental Part D Premium: | $60.80 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $33.59 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $461.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Devoted Health starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, DEVOTED C-SNP PLUS 003 HI may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | $18.00 copay |
| Generic | $0.00 copay | $19.00 copay |
| Preferred Brand | 15% coinsurance | 25% coinsurance |
| Non-Preferred Drug | 25% coinsurance | 31% coinsurance |
| Specialty Tier | 26% coinsurance | 25% coinsurance |
| Select Care Drugs | Not available | $0.00 copay |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H5397)
CMS star ratings reflect how well a Medicare plan performs across key quality measures, such as managing chronic conditions, member satisfaction, and customer service. Ratings range from 1 to 5 stars and are updated each year by Medicare.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
| Managing Chronic (Long Term) Conditions | Plan too new to be measured |
| Member Experience with Health Plan | Plan too new to be measured |
| Complaints and Changes in Plans Performance | Plan too new to be measured |
| Health Plan Customer Service | Plan too new to be measured |
| Drug Plan Customer Service | Plan too new to be measured |
| Complaints and Changes in the Drug Plan | Plan too new to be measured |
| Member Experience with the Drug Plan | Plan too new to be measured |
| Drug Safety and Accuracy of Drug Pricing | Plan too new to be measured |
Contact Information for Devoted Health
- Website
- Devoted Health Plan Page
- Providers
- Devoted Health Providers Page
- Formulary
- Devoted Health Formulary Page
- Pharmacy
- Devoted Health Pharmacy Page
- New Member Health Plan Help
- (844)978-2770
- New Member Health Plan TTY
- 711
- New Member Part D Help
- (844)978-2770
- New Member Part D TTY Users
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
DEVOTED C-SNP PLUS 003 HI (H5397-003-0) is available in the following locations (click to open):
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | CMS Version |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | CY2027 Landscape (202609.1) |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | 2027 Star Ratings Data Tables |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | PBP Benefits-2027 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | 2026-09 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Devoted Health (official source) | http://www.devoted.com | October 4, 2026 |
| CMS.gov | Chronic Condition Special Needs Plans (C-SNPs) | April 28, 2026 |
| CMS.gov | Medicare Advantage Plan Fact Sheet | April 28, 2026 |
| Medicare.gov | Joining a plan | April 28, 2026 |
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