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Devoted LIBERTY San Antonio (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted LIBERTY San Antonio (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted LIBERTY San Antonio (HMO) in 2025, please refer to our full plan details page.
Devoted LIBERTY San Antonio (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in San Antonio. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Devoted LIBERTY San Antonio (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Devoted LIBERTY San Antonio (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 LIBERTY San Antonio (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 $155.00. 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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9350.00 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
Prescription drugs are not covered by Devoted LIBERTY San Antonio (HMO).
Additional Benefits
The Devoted LIBERTY San Antonio (HMO) plan offers a range of benefits, including coverage for inpatient and outpatient services, with varying copays depending on the service. Emergency services, primary care, preventive services, and home health services are covered, with some services having no copay. Additional benefits include dental, vision, and hearing services with set copays and annual maximums. This plan also covers ambulance services, partial hospitalization, and home infusion services, as well as medical equipment. The plan has some cost-sharing requirements, such as copays for specialist visits, hearing exams, and vision services, and coinsurance for air ambulance and dialysis services. However, some services like preventive care and lab services have no copay.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, and require prior authorization. For Inpatient Hospital-Acute, you will pay a $425 copay for days 1-4, and no copay for days 5-90. For Inpatient Hospital Psychiatric, you will also pay a $425 copay for days 1-4, and no copay for days 5-90. Additional Days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, outpatient substance abuse services, and outpatient blood services, are covered by the Devoted LIBERTY San Antonio (HMO) plan. Outpatient hospital services have a copay between $0 and $525, observation services have a copay of $425, and Ambulatory Surgical Center (ASC) Services have no copay. Individual and group sessions for outpatient substance abuse have a copay of $45.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted LIBERTY San Antonio (HMO) plan, but requires prior authorization. You will have a $70 copay for this benefit.
Ambulance and Transportation Services See details
The Devoted LIBERTY San Antonio (HMO) plan covers ambulance services, including ground ambulance with a copay between $0 and $350, and air ambulance with 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services under the Devoted LIBERTY San Antonio (HMO) plan includes a $110 copay, and no coinsurance. Urgently Needed Services have a copay between $0 and $45, with no coinsurance. Worldwide Emergency Services include a $110 copay for Worldwide Emergency and Urgent Coverage, a 20% coinsurance and a $350 copay for Worldwide Emergency Transportation.
Primary Care See details
The Devoted LIBERTY San Antonio (HMO) plan covers Primary Care Physician Services, Occupational Therapy Services (with a $35 copay), Physician Specialist Services (with a $45 copay), Mental Health Specialty Services (with a $45 copay for individual or group sessions), Physical Therapy and Speech-Language Pathology Services (with a $45-$50 copay), and Additional Telehealth Benefits (with a $0-$45 copay). Chiropractic Services covers some services, but not Routine Chiropractic Care. Other services covered include Other Health Care Professional (with a $0-$45 copay), Psychiatric Services (with a $45 copay for individual or group sessions), and Opioid Treatment Program Services (with a $45 copay). Podiatry Services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs with no copay. In-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission prevention, wigs for hair loss, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers, additional sessions of smoking cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services are not covered.
Hearing Services See details
Hearing services with the Devoted LIBERTY San Antonio (HMO) plan include hearing exams with a $45 copay, routine hearing exams (1 per year), and fitting/evaluation for hearing aids (unlimited). Prescription hearing aids (all types) are covered with a copay between $599 and $899 for 2 per year, but prescription hearing aids for the inner ear, outer ear, or over the ear are not covered, and neither are OTC hearing aids.
Vision Services See details
Vision services include coverage for eye exams with a $45 copay, along with coverage for eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Eyewear has a combined maximum benefit of $250 per year.
Dental Services See details
The Devoted LIBERTY San Antonio (HMO) plan covers Medicare Dental Services with a $45 copay, and other dental services including oral exams, dental x-rays, and more with no copay. This plan has a $250 annual maximum benefit for dental services, and does not cover maxillofacial prosthetics, implant services, or orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. 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 a coinsurance of 0-20%.
Dialysis Services See details
Dialysis Services are covered by the Devoted LIBERTY San Antonio (HMO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 17% coinsurance and no copay, Prosthetics/Medical Supplies with a coinsurance for Medicare-covered devices and supplies, and Diabetic Equipment with some services not covered. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services with copays between $0 and $95, and lab services with no copay. Diagnostic Radiological Services have a maximum copay of $300, while Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Devoted LIBERTY San Antonio (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the listed sub-services are covered. The plan does not specify any cost sharing information for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted LIBERTY San Antonio (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are not covered, including acupuncture, over-the-counter items, and meal benefits. Additional services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and Private Duty Nursing Services are not covered.
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