In-network
Inpatient hospital
Days 1–7 $295 / day
Days 8–90 $0 / day
Total of listed copays · 7 charged days $2,065
● CMS 2026 plan record
DEVOTED CHOICE PREMIUM 004 IN (PPO)
Choose and order benefitsSelections are saved only on this device.
Emergency transport
Ambulance
Ground · in-network$0–$315 copay
Air · in-network20% coinsurance
Emergency services
Emergency room
$130 copay
Waived if admitted within 24 hours
Medical maximum
Maximum out-of-pocket
In-network$4,500
Combined in + out$10,100
Skilled care at home
Home health
In-networkCost share not reported
Out-of-network40% coinsurance
Monthly cost
Premium & giveback
Part C premium$0 / month
Consolidated C + D$11.40 / month
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Primary care physician
In: Cost share not reported · Out: $5 copay
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Specialist
In: $35 copay · Out: $35 copay
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Preventive care
In: Cost share not reported · Out: Cost share not reported
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Diagnostic procedures & tests
In: $0–$95 copay · Out: $0–$95 copay
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Laboratory services
In: $0–$20 copay · Out: $0–$20 copay + 20% coinsurance
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X-rays & standard imaging
In: $0–$300 copay · Out: $0–$300 copay
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MRI, CT & PET imaging
In: 20% coinsurance · Out: 40% coinsurance
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Urgent care
In: Cost share not reported · Out: Not separately reported
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Emergency room
In: $130 copay · Out: Not separately reported
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Ground ambulance
In: $0–$315 copay · Out: $0–$315 copay
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Air ambulance
In: 20% coinsurance · Out: 20% coinsurance
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Outpatient hospital
In: $0–$395 copay · Out: $0–$395 copay
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Outpatient surgery / ASC
In: $0–$295 copay · Out: $0–$295 copay
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Home health
In: Cost share not reported · Out: 40% coinsurance
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Skilled nursing facility
In: Cost share not reported · Out: Not separately reported
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Cardiac & pulmonary rehabilitation
In: $35 copay · Out: $35 copay
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Occupational therapy
In: $35–$50 copay · Out: $35–$50 copay
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Physical & speech therapy
In: $35–$50 copay · Out: $35–$50 copay
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Mental health services
In: $60 copay · Out: $60 copay
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Substance use treatment
In: $60 copay · Out: $60 copay
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Podiatry
In: $35 copay · Out: $35 copay
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Chiropractic
In: $15 copay · Out: $15 copay
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Dental
In: $35 copay · Out: $35 copay
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Vision
In: Cost share not reported · Out: Cost share not reported
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Hearing
In: $199–$499 copay · Out: $199–$499 copay
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Transportation
Not reported in this CMS export
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Fitness & wellness
In: Cost share not reported · Out: Cost share not reported
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Over-the-counter allowance
Not reported in this CMS export
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Meals
In: Cost share not reported · Out: Cost share not reported
Plan details
All plan benefits
No benefits match that search.
Medical care3 benefits
Primary care physician
In-networkCost share not reported
Out-of-network$5 copay
Specialist
In-network$35 copay
Out-of-network$35 copay
Preventive care
In-networkCost share not reported
Out-of-networkCost share not reported
Diagnostics & imaging4 benefits
Diagnostic procedures & tests
In-network$0–$95 copay
Out-of-network$0–$95 copay
Laboratory services
In-network$0–$20 copay
Out-of-network$0–$20 copay + 20% coinsurance
X-rays & standard imaging
In-network$0–$300 copay
Out-of-network$0–$300 copay
MRI, CT & PET imaging
In-network20% coinsurance
Out-of-network40% coinsurance
Urgent & hospital care6 benefits
Urgent care
In-networkCost share not reported
Out-of-networkNot separately reported
Emergency room
In-network$130 copay
Out-of-networkNot separately reported
Ground ambulance
In-network$0–$315 copay
Out-of-network$0–$315 copay
Air ambulance
In-network20% coinsurance
Out-of-network20% coinsurance
Outpatient hospital
In-network$0–$395 copay
Out-of-network$0–$395 copay
Outpatient surgery / ASC
In-network$0–$295 copay
Out-of-network$0–$295 copay
Recovery & therapy5 benefits
Home health
In-networkCost share not reported
Out-of-network40% coinsurance
Skilled nursing facility
In-networkCost share not reported
Out-of-networkNot separately reported
Cardiac & pulmonary rehabilitation
In-network$35 copay
Out-of-network$35 copay
Occupational therapy
In-network$35–$50 copay
Out-of-network$35–$50 copay
Physical & speech therapy
In-network$35–$50 copay
Out-of-network$35–$50 copay
Behavioral health2 benefits
Mental health services
In-network$60 copay
Out-of-network$60 copay
Substance use treatment
In-network$60 copay
Out-of-network$60 copay
Specialty care2 benefits
Podiatry
In-network$35 copay
Out-of-network$35 copay
Chiropractic
In-network$15 copay
Out-of-network$15 copay
Supplemental benefits7 benefits
Dental
In-network$35 copay
Out-of-network$35 copay
Vision
In-networkCost share not reported
Out-of-networkCost share not reported
Hearing
In-network$199–$499 copay
Out-of-network$199–$499 copay
Transportation
Not reported in this CMS exportNot reported in this CMS export
Fitness & wellness
In-networkCost share not reported
Out-of-networkCost share not reported
Over-the-counter allowance
Not reported in this CMS exportNot reported in this CMS export
Meals
In-networkCost share not reported
Out-of-networkCost share not reported
Plan costs & rulesCoverage overview
Premium & Part B giveback
$0 Part C premium / month · Part B giveback not separately reported
Maximum out-of-pocket (MOOP)
In-network$4,500
Combined in + out$10,100
Medical deductibles
In-networkNot reported
Out-of-networkNot reported
Network & referrals
Local PPO · Referrals: Not required · Out-of-network coverage: Yes
Prescription drugs5 tiers
Part D deductible
Not reported
Drug tier 1
$0 retail copay · 30-day supply
Drug tier 2
$3 retail copay · 30-day supply
Drug tier 3
22% retail coinsurance · 30-day supply
Drug tier 4
25% retail coinsurance · 30-day supply
Drug tier 5
25% retail coinsurance · 30-day supply
Using this plan
Understand H7471-004-000
Plain-language context built from this plan’s 2026 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.
Plan at a glance
A quick read on this plan
DEVOTED CHOICE PREMIUM 004 IN (PPO) is a 2026 Local PPO offered by Devoted Health in Northeast Indiana. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $2,065 across 7 charged days.
Common benefit costs
What you may pay
These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.
Routine care
- Primary care physician
- Cost share not reported
- Specialist
- $35 copay
- Laboratory services
- $0–$20 copay
Separate visits or services; costs are not added together.
Tests & outpatient care
- Diagnostic procedures & tests
- $0–$95 copay
- MRI, CT & PET imaging
- 20% coinsurance
- Outpatient hospital
- $0–$395 copay
The service setting and billing details can change what you pay.
Emergency & hospital care
- Emergency room
- $130 copay
- Listed inpatient stages
- $2,065 total
7 charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.
Helpful context
Terms worth knowing
Maximum out-of-pocket (MOOP)
This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.
Availability
Who can enroll
- Service area
- Northeast Indiana (IN)
- Plan type
- Local PPO
- Contract / plan
- H7471-004
- Coverage year
- 2026
Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.
Supplemental coverage
Extra benefits reported
Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.
Dental$35 copay
VisionCost share not reported
Hearing$199–$499 copay
Fitness & wellnessCost share not reported
MealsCost share not reported
Plan-specific answers
Frequently asked questions
Where is H7471-004-000 available?
DEVOTED CHOICE PREMIUM 004 IN (PPO) is listed for Northeast Indiana (IN). Enrollment generally requires Medicare eligibility and residence in the plan's service area.
What is the in-network maximum out-of-pocket limit for H7471-004-000?
The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $4,500. Prescription drug spending generally does not count toward this medical limit.
What is the monthly plan premium for H7471-004-000?
The listed consolidated Part C and Part D premium is $11.40 per month. This does not replace the standard Medicare Part B premium.
What does an emergency room visit cost on H7471-004-000?
The plan record lists $130 copay, waived when an admission meets the plan's stated timing rule.
Does H7471-004-000 report extra benefits?
Yes. CMS reports dental, vision, hearing, fitness & wellness, meals. See the detailed benefit rows and official plan documents for limits and conditions.
Source trail
Official CMS, Contract Year 2026
Plan identity and benefits come from CMS PBP data. Premium and MOOP figures are cross-checked against the August 2026 Landscape release; county identity is sourced from segment-level Landscape rows and stable codes are enriched from the aligned MA contract service-area release where matched. Quick-reference values should be confirmed in 2026 official plan documents.
Plan context
Where H7471-004-000 fits
- Full CMS plan ID
H7471-004-000- Contract
H7471- Base plan code
H7471-004- Segment
000- Carrier
- Devoted Health
- Plan type
- Local PPO
- Service area
- Northeast Indiana (IN)
County/service-area foundation
CMS service-area entries
Named county entries are tied to this exact contract, plan, and segment in CMS Landscape data. County codes are enriched from the aligned CMS contract service-area release where a match exists.
- Adams, IN
- Blackford, IN
- DeKalb, IN
- Grant, IN
- Huntington, IN
- Jay, IN
- Lagrange, IN
- Noble, IN
- Steuben, IN
- Wabash, IN
- Wells, IN
- Whitley, IN
About this code
What H7471-004-000 identifies
H7471-004-000 is a Contract Year 2026 Medicare plan segment code. Searches written as H7471-004, H7471 004, or the compact full CMS ID H7471004000 refer to this plan or its base plan code.
Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.