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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 2026, 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 4 out of 5 stars in 2026.
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 $615.00 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 $3500.00 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 features an annual prescription drug deductible of $615. Under this plan, you will pay no copay for Tier 1 preferred generics, Tier 2 generics, and Tier 6 select care drugs when using a preferred pharmacy or preferred mail-order service. If you choose a standard pharmacy, copays for Tier 1 and Tier 2 generic drugs start as low as $5 for a one-month supply. For higher-tier medications, costs are structured as a percentage of the drug cost rather than a flat fee. Tier 3 preferred brands and Tier 5 specialty drugs both require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 35% coinsurance at preferred pharmacies and 36% coinsurance at standard pharmacies.
Additional Benefits
Wellcare Simple (HMO) offers budget-friendly healthcare coverage, featuring no copays for primary care visits, routine preventive services, and home health care. Specialist visits require a low $15 copay, while inpatient hospital stays have a $325 copay for the first six days of acute stays and emergency room visits carry a $150 copay. Most covered services under this plan feature no coinsurance, helping to keep your out-of-pocket costs predictable. This plan also includes valuable supplemental benefits, offering no copay for routine dental care up to a $2,000 annual limit, routine vision exams with up to $300 for eyewear, and routine hearing exams with a $750 annual hearing aid allowance per ear. Additionally, members enjoy no copays for over-the-counter items, chronic illness meal benefits, and the first 20 days of skilled nursing facility care. For specialized medical needs, durable medical equipment and dialysis services are covered with a 20% coinsurance and no copay.
Inpatient Hospital See details
Wellcare Simple (HMO) covers inpatient hospital services with no coinsurance, requiring a $325 copay for days 1 through 6 of acute stays and a $250 copay for days 1 through 5 of psychiatric stays, with no copay for the remaining covered days. This benefit is partially covered, as upgrades, additional psychiatric days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Wellcare Simple (HMO) covers outpatient services with no coinsurance, featuring a copay of $0 to $280 for outpatient hospital services and $75 for ambulatory surgical center services. Outpatient substance abuse sessions have a $25 copay with no coinsurance, and outpatient blood services are covered with no copay, coinsurance, or deductible.
Partial Hospitalization See details
Wellcare Simple (HMO) covers partial hospitalization services with a $175.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Wellcare Simple (HMO) covers ground and air ambulance services with a $250 copay per service and no coinsurance, with prior authorization required. Transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
Wellcare Simple (HMO) covers emergency services with a $150 copay and no coinsurance, and urgently needed services with a $20 copay and no coinsurance, with both copays waived if you are admitted to the hospital within 24 hours. Worldwide emergency and urgent services are partially covered up to a $50,000 maximum benefit with a $150 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple (HMO) features primary care physician services with no copay and no coinsurance, while specialist, physical therapy, and occupational therapy visits require a $15 copay and no coinsurance. Mental health and psychiatric services have a $25 copay and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Wellcare Simple (HMO) covers preventive services, including annual physicals and select screenings, with no copay and no coinsurance, though kidney disease education requires a 20% coinsurance with no copay. Additional preventive benefits are partially covered, providing fitness benefits, alternative therapies, and remote access with no copay, while health education, weight management, and in-home safety assessments are not covered.
Hearing Services See details
Wellcare Simple (HMO) covers Medicare-covered hearing exams for a $15 copay and no coinsurance, while routine exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with no copay, no coinsurance, and a $750 annual maximum benefit per ear, but OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Wellcare Simple (HMO) partially covers vision services with no coinsurance, featuring no copay for one routine annual eye exam and up to a $15 copay for other covered exams, though other eye exam services are not covered. Eyewear, including glasses and contacts, is covered with no copay up to a $300 yearly benefit limit, and prior authorization is required.
Dental Services See details
Wellcare Simple (HMO) offers partially covered dental services with no copay and no coinsurance for preventive and most comprehensive care up to a $2,000 annual limit, while Medicare-covered dental has a $15 copay and no coinsurance. Prior authorization is required for most treatments, and maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Wellcare Simple (HMO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require a 0% to 20% coinsurance.
Dialysis Services See details
Wellcare Simple (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Wellcare Simple (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance. Covered diabetic supplies feature no copay, while diabetic therapeutic shoes and inserts require a 20% coinsurance and no copay.
Diagnostic and Radiological Services See details
Wellcare Simple (HMO) covers diagnostic and radiological services with prior authorization, featuring no coinsurance and no copay for lab services, and a $0 to $25 copay for diagnostic tests. Radiological services require a $25 copay for X-rays, a $0 minimum copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered by Wellcare Simple (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Wellcare Simple (HMO) with no copay and no coinsurance, but some services are covered while standard cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Wellcare Simple (HMO) covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 to 20 and days 41 to 100, while days 21 to 40 require a $218 daily copay, with additional days beyond the standard Medicare limit not covered.
Other Services See details
Wellcare Simple (HMO) partially covers other services, offering over-the-counter (OTC) items and chronic illness meal benefits with no copay and no coinsurance, while acupuncture is not covered. A referral is required for the meal benefit, and OTC items are available through reimbursement.
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