DEVOTED C-SNP CHOICE PLUS 020 TN (PPO C-SNP)
H9231-020 • 2026 • Hamilton County, TN
DEVOTED C-SNP CHOICE PLUS 020 TN (PPO C-SNP) H9231-020 • 2026 • Hamilton County, TN
DEVOTED C-SNP CHOICE PLUS 020 TN is a Medicare Chronic or Disabling Condition plan offered by Devoted Health for the 2026 plan year. It is identified by CMS Plan ID H9231-020 and serves individuals who meet defined eligibility criteria.
DEVOTED C-SNP CHOICE PLUS 020 TN Overview
Plan Overview for H9231-020-0 | |
|---|---|
| CMS Plan ID: | H9231-020-0 |
| Plan Type: | PPO C-SNP |
| Plan Year: | 2026 |
| Monthly Premium: | $27.70 Plus your Medicare Part B premium. |
| Medical Deductible: | $850 |
| Maximum Out-of-Pocket: | $9250.00 (In-Network) |
| Part B Give Back: | Not offered |
| Prescription Drug Coverage: | Basic, $615.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Service Area: | Hamilton County, TN |
| Enrollment (Nationwide) | 456 beneficiaries |
| Enrollment (CMS – Local) | 51 beneficiaries in Hamilton County |
| Provided By: | Devoted Health |
Plan Overview and Eligibility
- DEVOTED C-SNP CHOICE PLUS 020 TN is a Chronic Condition Special Needs Plan (C-SNP) designed for people with qualifying health conditions.
- Eligibility requires Medicare Part A and Part B and residence in Hamilton County.
- The plan operates on a PPO network and includes Medicare Part D drug coverage. The annual Part D deductible is $615.00.
- It includes all standard Medicare benefits, along with plan-specific coverage enhancements.
- Cost-sharing may differ from Original Medicare depending on the service used.
DEVOTED C-SNP CHOICE PLUS 020 TN uses a Preferred Provider Organization (PPO) network for delivery of care. As a PPO member, you can receive services from both in-network and out-of-network providers, typically at a lower cost when using the plan’s network. Referrals are not usually required to see specialists. Emergency care and out-of-area dialysis are covered.
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 | Out-of-network: 40% coinsurance |
| Specialist: | In-network: 30% coinsurance | Out-of-network: 40% coinsurance |
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%-30% coinsurance |
| Routine chiropractic: | Not covered |
| Fitness benefits: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Health education: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Counseling services: | Not covered |
| Over-the-counter drug benefits: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| 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: 50% coinsurance | Out-of-network: 50% coinsurance |
| Lab services: | In-network: 50% coinsurance | Out-of-network: 50% coinsurance |
| Outpatient x-rays: | In-network: 50% coinsurance | Out-of-network: 50% coinsurance |
| Diagnostic tests and procedures: | In-network: 0%-50% coinsurance | Out-of-network: 0%-50% coinsurance |
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: | $115 copay |
| Worldwide emergency care: | $0 copay |
| Urgent care: | 0%-20% coinsurance |
| Inpatient hospital care: | In-network: | Tier 1 | $2,230 per stay | Out-of-network: | 40% per stay |
| Skilled Nursing Facility: | In-network: | Tier 1 | $0 per day for days 1-20 | $218 per day for days 21-100 | Out-of-network: | 40% per stay |
| Ground ambulance: | In-network: 0%-50% coinsurance | Out-of-network: 0%-50% coinsurance |
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: 30% coinsurance | Out-of-network: 40% coinsurance |
| Outpatient group therapy: | In-network: 30% coinsurance | Out-of-network: 40% coinsurance |
| Inpatient psychiatric hospital care: | In-network: | Tier 1 | $2,230 per stay | Out-of-network: | 40% 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: 30% coinsurance | Out-of-network: 40% coinsurance |
| Occupational therapy: | In-network: 30% coinsurance | Out-of-network: 40% coinsurance |
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: 20% coinsurance | Out-of-network: 50% coinsurance |
| Durable medical equipment: | In-network: 20% coinsurance | Out-of-network: 50% coinsurance |
| Prosthetics: | In-network: 0%-20% coinsurance | Out-of-network: 0%-50% 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%-20% coinsurance | Out-of-network: 50% coinsurance |
| Other Part B drugs (Medicare-covered): | In-network: 0%-20% coinsurance | Out-of-network: 0%-50% 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 | Out-of-network: $0 copay, 0% coinsurance |
| Dental x-rays: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Cleaning: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Periodontics: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Endodontics: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Restorative services: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Implant services: | Not covered |
| Orthodontics: | Not covered |
| Oral/Maxillofacial surgery: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
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 | Out-of-network: $0 copay, 0% coinsurance |
| Contact lenses: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass frames only: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass lenses only: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglasses (frames & lenses): | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Upgrades: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
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 | Out-of-network: $0 copay, 0% coinsurance |
| Fitting/evaluation: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Prescription hearing aids: | In-network: $399-$699 copay | Out-of-network: $399-$699 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 | Out-of-network: $0 copay, 0% coinsurance |
| Wigs for chemotherapy-related hair loss: | Not covered |
| Alternative therapies: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Massage therapy: | Not covered |
| Home/bathroom safety devices: | In-network: $0 copay | Out-of-network: 50% coinsurance |
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: | $27.70 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $27.70 |
| Low Income Premium Subsidy: | $27.74 |
| Low Income Premium Subsidy CMS Pays: | $27.70 |
| 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 C-SNP CHOICE PLUS 020 TN 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 | $18.00 copay | Coming soon |
| Generic | $19.00 copay | Coming soon |
| Preferred Brand | 25% coinsurance | Coming soon |
| Non-Preferred Drug | 31% 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 H9231-020-0 – 2026
| CMS Measure | Star Rating (out of 5) |
|---|---|
| 2026 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Not enough data available |
| Managing Chronic (Long Term) Conditions | Not enough data available |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | Not enough data available |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | Not enough data available |
| 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, "Chronic Condition Special Needs Plans (C-SNPs)" — Last accessed April 28, 2026
- Medicare.gov, "Compare types of Medicare Advantage Plans" — Last accessed April 28, 2026
- NCOA.org, "5 Steps to Choosing the Right Medicare Plan for You" — Last accessed April 28, 2026
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