DEVOTED C-SNP PREMIUM 014 MO (HMO C-SNP) Costs & Coverage, Hickory County, Missouri
DEVOTED C-SNP PREMIUM 014 MO (HMO C-SNP) Costs & Coverage, Hickory County, Missouri
Explore the benefits and costs of DEVOTED C-SNP PREMIUM 014 MO (HMO C-SNP), a 2026 Medicare Special Needs Plan designed to meet your unique healthcare needs. Review this plan to understand how it aligns with your health and financial goals.
This Devoted Health HMO C-SNP plan is required to provide all of the same benefits as Original Medicare, but out-of-pocket costs are different. Available to qualified individual living in Hickory County, MO, DEVOTED C-SNP PREMIUM 014 MO may include extra benefits not covered by Medicare Part A or Part B.
Based on CMS enrollment data, an estimated 0 Medicare beneficiaries are enrolled in this plan, with 0 members in Hickory County, MO.
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system. The Devoted Health logo is a registered trademark.[2]
DEVOTED C-SNP PREMIUM 014 MO Overview
| Plan ID H2041-014-0 Overview | |
|---|---|
| Health Plan ID: | H2041-014-0 |
| Medicare Advantage Plan Type: | HMO C-SNP |
| Plan Year: | 2026 |
| Monthly Premium: | $43.00 Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Annual Out-of-Pocket Maximum: | $4200.00 (In-Network) |
| Part B Give Back: | Not offered |
| Part D Drug Plan Benefit: | Basic, $615.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Availability: | Hickory County, MO |
| Insured By: | Devoted Health |
We're Here to Help You Enroll
Health Plan Cost Sharing & Benefits
DEVOTED C-SNP PREMIUM 014 MO is a Health Maintenance Organization (HMO) plan. As an HMO member, you typically receive healthcare services through the plan’s local network of providers, with referrals generally required to see specialists and other providers. However, DEVOTED C-SNP PREMIUM 014 MO does cover out-of-network care for emergencies and out-of-area dialysis.
Find out the costs for visiting your primary care doctor and specialists, as well as coverage for wellness and preventive programs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | In-network: $0 copay |
| Specialist: | In-network: $35 copay |
Medicare Advantage plans often include preventive and wellness benefits designed to help members stay healthy, identify risks early, and maintain an active lifestyle.
| Service | Enrollee Cost (in-network) |
|---|---|
| Annual wellness exam: | In-network: $0 copay |
| Telehealth benefit: | In-network: $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 |
Review the costs for emergency services, urgent care, ambulance services, inpatient hospital stays, and skilled nursing facility care.
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $150 copay |
| Wordwide emergency care: | $150 copay |
| Urgent care: | $0-$45 copay |
| Inpatient hospital care: | Tier 1 | $380 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 | $218 per day for days 21-100 |
| Ground ambulance: | In-network: $0-$315 copay |
This section explains the costs for mental health services, including individual and group therapy, and inpatient care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | In-network: $35 copay |
| Outpatient group therapy: | In-network: $35 copay |
| Inpatient psychiatric hospital care: | Tier 1 | $380 per day for days 1-6 | $0 per day for days 7-90 | $0 per stay |
See the cost details for rehabilitation services, including physical therapy, speech therapy, and occupational therapy.
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | In-network: $35-$50 copay |
| Occupational therapy: | In-network: $35-$50 copay |
Learn about the costs associated with medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | In-network: 0%-50% coinsurance |
| Durable medical equipment: | In-network: 20%-50% coinsurance |
| Prosthetics: | In-network: 0%-20% coinsurance |
This section outlines the costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | In-network: $0-$300 copay |
| Lab services: | In-network: $0-$20 copay |
| Outpatient x-rays: | In-network: $0-$75 copay |
| Diagnostic tests and procedures: | In-network: $0-$95 copay |
Review the cost-sharing details for chemotherapy and other Medicare Part B-covered drugs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | In-network: 0%-20% coinsurance |
| Other Part B drugs (Medicare-covered): | In-network: 0%-20% coinsurance |
This section details the dental services covered under your plan including Medicare-covered preventive dental, oral exams, x-rays, dental cleanings, and comprehensive dental.
| Service | Member Cost (in-network) |
|---|---|
| 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: | Not covered |
| Orthodontics: | Not covered |
| Oral/Maxillofacial surgery: | In-network: $0 copay |
This section outlines the coverage for hearing-related services, including exams, fittings, and hearing aids.
| Service | Member Cost (in-network) |
|---|---|
| Hearing exam: | In-network: $0 copay |
| Fitting/evaluation: | In-network: $0 copay |
| Prescription hearing aids: | In-network: $399-$699 copay |
| OTC hearing aids: | Not covered |
Learn about the costs for vision-related services, including eye exams, eyeglasses, and contact lenses.
| Service | Member Cost (in-network) |
|---|---|
| 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 |
Medicare Advantage plans may include extra benefits and special needs services designed to support members with chronic conditions, mobility limitations, or other complex health needs.
| Service | Enrollee Cost (in-network) |
|---|---|
| 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 hair loss: | Not covered |
| Alternative therapies: | In-network: $0 copay |
| Massage therapy: | Not covered |
| Home/bathroom safety devices: | In-network: $0 copay |
Do you have questions about the costs in this plan? Call 1-833-748-3201 (TTY 711) to speak with a licensed HealthCompare insurance agent (Mon-Fri 5am-6pm, Sat 6am-5pm PST) and learn more about this Special Needs Plan (H2041-014-0) and other plans on this site.
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: | $43.00 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $43.00 |
| Low Income Premium Subsidy: | $43.03 |
| Low Income Premium Subsidy CMS Pays: | $43.00 |
| Low Income Subsidy Premium: | $0.00 |
For more information about the Low Income Subsidy, refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D 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.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, DEVOTED C-SNP PREMIUM 014 MO has out-of-pocket costs that you must pay when you pick up your prescriptions. The following table shows you those costs.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $18.00 copay | Coming soon |
| Generic | $20.00 copay | Coming soon |
| Preferred Brand | 23% coinsurance | Coming soon |
| Non-Preferred Drug | 26% coinsurance | Coming soon |
| Specialty Tier | 25% coinsurance | Coming soon |
| Select Care Drugs | $0.00 copay | Coming soon |
| *Deductible does not apply. | ||
CMS Rating Marks
Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates Medicare Advantage HMO C-SNPs across nine broad categories using a 5-star rating system. These star ratings provide insight into the quality of care and service you can expect from this Devoted Health plan.
CMS Star Ratings for Plan H2041-014-0 – 2026
| CMS Measure | Star Rating (out of 5) |
|---|---|
| 2026 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 | |
| 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 |
Eligibility Criteria for Enrolling in DEVOTED C-SNP PREMIUM 014 MO
To enroll in DEVOTED C-SNP PREMIUM 014 MO, you must meet the following criteria:
- You are eligible for Medicare;
- You reside within the plan’s service area; and
- You have been diagnosed with one or more severe or disabling chronic conditions.
Medicare Special Needs Plan Enrollment Periods
After determining your eligibility for DEVOTED C-SNP PREMIUM 014 MO, it’s important to be aware of the Medicare Enrollment Periods, which determine when you can enroll in or change your plan. Depending on your circumstances, one of the following periods will apply:
- Initial Enrollment Period (IEP): Your first opportunity to enroll when you become eligible for Medicare.
- Annual Enrollment Period (AEP): The time each year when you can change your Medicare plan or enroll in a new one.
- Special Enrollment Periods (SEPs): Times outside of AEP when you can make changes due to specific circumstances, such as moving to a new area or losing other insurance coverage.
For comprehensive information on these enrollment periods, learn more here and make well-informed Medicare decisions.
Contact Devoted Health
Call 833-748-3201 (TTY 711) to speak with a licensed HealthCompare insurance agent (Mon-Fri 5am-6pm, Sat 6am-5pm PST) and learn more about this plan and other plans on this site. You may also Enroll Online.
| 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 |
If you qualify for Medicare benefits but have not yet enrolled or verified your status, visit Social Security Administration website or Medicare.gov.
- CMS.gov, Landscape Source Files — Last accessed September 26, 2025
- CMS.gov, Medicare Part C & D Performance — Last accessed October 10, 2025
- CMS.gov, Plan Benefits Package — Last accessed October 15, 2025
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County — Last accessed October 13, 2025
Learn more about how we use CMS data.
- Devoted Health, http://www.devoted.com — Last accessed October 13, 2025
- CMS.gov, "Chronic Condition Special Needs Plans (C-SNPs)" — Last accessed September 20, 2025
- Medicare.gov, "Understanding Medicare Advantage Plans" — Last accessed 25 May, 2025
- NCOA.org, "5 Steps to Choosing the Right Medicare Plan for You" — Last accessed 5 May, 2025
Medicare.org is owned and operated by Health Network Group, LLC, an Allstate company. Medicare.org provides information only and is not connected with or endorsed by the U.S. Government or the federal Medicare program.
Data provenance documentation is maintained in alignment with the U.S. Core Data for Interoperability (USCDI) Provenance standard.
Page content managed by David Bynon, Medicare Analyst.