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Wellcare Simple (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Simple (HMO) in 2025, please refer to our full plan details page.
Wellcare Simple (HMO) is a HMO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select counties in TX. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Wellcare Simple (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 Wellcare Simple (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 Wellcare Simple (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.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 $420.00 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 $5000.00 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 Wellcare Simple (HMO) plan has a $420 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For the initial coverage phase, preferred generic drugs have no copay at preferred pharmacies and mail order, and a $10 copay at standard pharmacies. Standard generic drugs have 25% coinsurance, preferred brand drugs have 42% coinsurance, non-preferred drugs have 28% coinsurance, and specialty tier drugs have no copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Wellcare Simple (HMO) plan offers a range of benefits with varying cost structures. Inpatient hospital stays have copays that differ based on the type of care and length of stay. Outpatient services, including doctor visits, have copays, while preventive services like annual physicals and many vision and dental services have no copay. Additional benefits include coverage for ambulance and transportation services, emergency services, hearing aids, and some home health services, each with specific copays or coinsurance. The plan also covers services like home infusion, dialysis, and medical equipment, with copays or coinsurance applying. Additionally, the plan offers benefits such as an OTC benefit, and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both requiring prior authorization. For Inpatient Hospital-Acute, you'll pay a $350 copay for days 1-6, and no copay for days 7-90, while Inpatient Hospital Psychiatric has a $300 copay for days 1-6, and no copay for days 7-90. Additional days and non-Medicare covered stays for both are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $350, observation services with a copay between $125 and $350, ambulatory surgical center services with a $250 copay, outpatient substance abuse services with a $25 copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Wellcare Simple (HMO) plan, but requires prior authorization. You will have a copay of $105 for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required. Ground and air ambulance services have a $250 copay, while transportation services to a plan-approved health-related location have no copay for up to 24 one-way trips per year, using rideshare, bus/subway, or medical transport. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Coverage, are covered under the Wellcare Simple (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, and Urgently Needed Services have a $35 copay; all have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, and physician specialist services with a $25 copay. The plan also covers mental health specialty services with a $25 copay, other health care professional services with a $0-$25 copay, psychiatric services with a $25 copay, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits with a $0-$40 copay, and opioid treatment program services with a $25 copay. However, routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Wellcare Simple (HMO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, including glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit, are covered with no copay. Kidney disease education services have a 20% coinsurance. Certain services such as health education, in-home safety assessments, and others, are not covered.
Hearing Services See details
Wellcare Simple (HMO) covers hearing exams with a $25 copay, and routine hearing exams and fitting/evaluation for hearing aids with no copay. The plan also covers prescription hearing aids with a $500 maximum benefit per year, but does not cover prescription hearing aids for the inner ear, outer ear, or over the ear, and does not cover OTC hearing aids.
Vision Services See details
Wellcare Simple (HMO) covers vision services including eye exams and eyewear. Eye exams have a copay between $0 and $25, and routine eye exams have no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, have no copay, but have a combined maximum benefit of $200 per year.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $25 copay, Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, Other Preventive Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery with no copay. Orthodontic Services are covered up to a maximum of $2,000 per year, while Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
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. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, coinsurance applies, ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Wellcare Simple (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Supplies have no copay. Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Wellcare Simple (HMO) plan. Diagnostic Procedures/Tests have a copay between $0 and $30, Lab Services have no copay, and Diagnostic Radiological Services have a copay up to $300.00. Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have a $75 copay.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Wellcare Simple (HMO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple (HMO) plan. For days 1-20, there is no copay, for days 21-50, the copay is $214, and for days 51-100, there is no copay. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Wellcare Simple (HMO) plan covers Over-the-Counter (OTC) Items with no copay, and a meal benefit with no copay that requires a doctor's referral. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and several other services are not covered.
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