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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 $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 has a $420 deductible for prescription drugs. After the deductible is met, you will pay either a copay or coinsurance depending on the drug tier and the pharmacy you use. For the initial coverage phase, the plan has no copay for preferred generic and specialty tier drugs, and a $10 copay for standard generic drugs. Brand name and non-preferred drugs have 25-44% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs.
Additional Benefits
The Wellcare Simple (HMO) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays. You'll find no copays for primary care visits and routine hearing and vision exams, as well as many preventive services. The plan also includes benefits for dental, hearing, and vision, with coverage for prescription hearing aids and eyewear. Other key benefits include ambulance and transportation services, emergency services, and home health services with no copays. This plan covers home infusion services and dialysis, along with medical equipment and diagnostic services. Additional benefits include coverage for over-the-counter items and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $325 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric, you will pay a $250 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, as well as non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered by the Wellcare Simple (HMO) plan. Outpatient Hospital Services have a copay between $0 and $280, Observation Services have a copay between $140 and $280, Ambulatory Surgical Center (ASC) Services have a $75 copay, and Outpatient Substance Abuse Services have a copay of $25 for both individual and group sessions. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple (HMO) plan, but requires prior authorization. You will have a $130 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services with a $250 copay. Transportation services to a plan-approved health-related location are covered with no copay, offering 12 one-way trips per year via rideshare services, bus/subway, or medical transport, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage each have a $140 copay, and Worldwide Urgent Coverage also has a $140 copay; all of these services 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, and specialist, physical therapy, and speech-language pathology services for a $15 copay. Chiropractic services, occupational therapy, and mental health services have a $15-$25 copay, and other health care professional and opioid treatment program services have a $0-$15 copay. Additional telehealth benefits have a copay that ranges from $0 to $25. 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 Welcome Visit, have no copay. Kidney Disease Education Services have a 20% coinsurance. Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, 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, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
The Wellcare Simple (HMO) plan covers hearing exams with a $15 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a maximum benefit of $750 per year, and all types of prescription hearing aids are covered with no copay. OTC hearing aids, and prescription hearing aids for the inner, outer, and over the ear, are not covered.
Vision Services See details
Vision services are covered, including eye exams and eyewear. Eye exams have a copay of $0-$15, and routine eye exams have no copay. Eyewear has no copay, and includes contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental services include coverage for Medicare dental services with a $15 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. Maxillofacial prosthetics, implant services, and orthodontics are not covered. Orthodontic services are covered up to a maximum of $3,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
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) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a maximum copay of $25, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $150, Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a copay of $25.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple (HMO) plan with no copay and no coinsurance. 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 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 under the Wellcare Simple (HMO) plan, with a $0 copay for days 1-20, a $214 copay for days 21-40, and a $0 copay for days 41-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items and Meal Benefit with no copay, and a $131 maximum benefit every three months for OTC items; however, acupuncture, 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.
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