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Devoted GIVEBACK Missouri (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted GIVEBACK Missouri (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted GIVEBACK Missouri (HMO) in 2025, please refer to our full plan details page.
Devoted GIVEBACK Missouri (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Greater Kansas City. The overall rating for this plan is not yet available for 2025.
It's important to know that Devoted GIVEBACK Missouri (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Devoted GIVEBACK Missouri (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Devoted GIVEBACK Missouri (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $147.70. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $7000.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Devoted GIVEBACK Missouri (HMO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. During the initial coverage phase, after you pay the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you may pay a $10 copay for preferred generic drugs at standard or mail order pharmacies, and 25% coinsurance for standard generic, preferred brand, and non-preferred drugs. After your total drug costs reach $2000.00, you enter the catastrophic coverage phase where you will pay nothing for Part D covered drugs.
Additional Benefits
The Devoted GIVEBACK Missouri (HMO) plan offers comprehensive coverage, including inpatient hospital stays with a $475 copay for the first three days, and no copay for days 4-90. Outpatient services have copays ranging from $0 to $575, while emergency services have a $110 copay. This plan also covers primary care with copays between $15 and $45, along with hearing and vision services. Hearing exams have a $45 copay, and prescription hearing aids have copays between $599 and $899. Routine eye exams have a $45 copay, and eyewear has a combined maximum benefit of $250 per year. Dental services, home health, and skilled nursing facilities are also covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a $475 copay for days 1-3 and no copay for days 4-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $575, observation services with a $475 copay, ambulatory surgical center services with no copay, outpatient substance abuse services, individual sessions for outpatient substance abuse with a $45 copay, and group sessions for outpatient substance abuse with a $45 copay. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK Missouri (HMO) plan, with a copay of $80.00 and prior authorization required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted GIVEBACK Missouri (HMO) plan. Ground ambulance services have a copay between $0 and $300, while air ambulance services have a 20% coinsurance; transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted GIVEBACK Missouri (HMO) plan. Emergency Services have a $110 copay, while Urgently Needed Services have a copay between $0 and $45. Worldwide Emergency Transportation has a $300 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay.
Primary Care See details
Primary care includes coverage for primary care physician services. Chiropractic services have a $15 copay for routine care, while occupational therapy services have a $35 copay. Physician specialist services have a $45 copay, and mental health specialty services, including individual and group sessions, have a $45 copay. Other health care professional services have a copay between $0 and $45, and psychiatric services, including individual and group sessions, have a $45 copay. Physical therapy and speech-language pathology services have a $45-$50 copay, and additional telehealth benefits have a copay between $0 and $45. Opioid treatment program services have a $45 copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. In-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission prevention, wigs for hair loss related to chemotherapy, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services are not covered.
Hearing Services See details
Hearing Services include Hearing Exams, which have a $45 copay, and Prescription Hearing Aids, which have a copay between $599 and $899 for all types, with a limit of 2 per year. Prescription Hearing Aids are not covered for inner ear, outer ear, or over the ear.
Vision Services See details
The Devoted GIVEBACK Missouri (HMO) plan covers vision services, including routine eye exams with a $45 copay. This plan also covers eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, with a combined maximum plan benefit of $250 every year.
Dental Services See details
Dental services include coverage for Medicare dental services with a $45 copay. Other dental services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventative dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Devoted GIVEBACK Missouri (HMO) plan. There is a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 16-18% coinsurance and no copay, Prosthetic Devices with 0-20% coinsurance and no copay, and Medical Supplies with 20% coinsurance and no copay. Durable Medical Equipment for use outside the home and Diabetic Supplies/Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Devoted GIVEBACK Missouri (HMO) plan. Diagnostic Procedures/Tests have a copay between $0 and $95, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $300, and Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK Missouri (HMO) plan with no copay and no coinsurance, but prior authorization is required. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Devoted GIVEBACK Missouri (HMO) plan. Although the plan covers some Cardiac Rehabilitation Services, none of the sub-services are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Devoted GIVEBACK Missouri (HMO) plan, with prior authorization required. For days 1-20 and 61-100, there is no copay, but for days 21-60, the copay is $214.
Other Services See details
Other Services, including acupuncture, over-the-counter (OTC) items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services, are not covered. Other 2 benefits include $0 preventive services.
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