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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 $4500.00 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) prescription drug plan features an annual drug deductible of $615. You can enjoy no copay for Tier 1 preferred generics and Tier 2 generics when using preferred pharmacies or preferred mail-order services, while Tier 6 select care drugs have no copay across all pharmacy options. Standard pharmacy copays for generic drugs are also highly affordable, starting at just $5 for a one-month supply. For brand-name and specialty medications, costs are structured as coinsurance rather than flat copays. Tier 3 preferred brands and Tier 5 specialty drugs require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 36% coinsurance at preferred locations and 37% coinsurance at standard locations. This plan offers a practical balance of cost-free generic medications and reliable coverage for higher-tier prescription needs.
Additional Benefits
Wellcare Simple (HMO) offers affordable medical coverage featuring no copay for primary care visits and a low $15 copay for specialists, with no coinsurance required for either. Inpatient hospital stays require a daily copay for the first 6 days and no copay for subsequent days, while emergency room visits carry a $130 copay that is waived if you are admitted. Outpatient care, diagnostic procedures, and home health services are also covered, featuring no coinsurance and many services with no copays. For extra wellness needs, the plan provides routine dental, vision, and hearing benefits with no copay, including a $2,000 annual limit for dental care and a $100 allowance for eyewear. Additionally, members can access up to 12 free one-way transportation trips per year to approved health locations and a no-copay benefit for over-the-counter items. Durable medical equipment and dialysis services are also covered with no copay and a standard 20% coinsurance.
Inpatient Hospital See details
Wellcare Simple (HMO) covers inpatient hospital services with no coinsurance, featuring a $375 copay per day for days 1 to 6 of acute stays (no copay for days 7 to 95) and a $300 copay per day for days 1 to 6 of psychiatric stays (no copay for days 7 to 90). Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Wellcare Simple (HMO) covers outpatient services with no coinsurance, including outpatient hospital visits with a copay ranging from no copay to $280, observation services with a $130 to $280 copay per stay, and ambulatory surgical center services with a $200 copay. Outpatient substance abuse sessions require a $25 copay, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Wellcare Simple (HMO) covers partial hospitalization services with a $140.00 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
Wellcare Simple (HMO) covers ground and air ambulance services with a $300 copay and no coinsurance. Transportation services are partially covered, providing up to 12 one-way trips per year to plan-approved health-related locations with no copay and no coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Wellcare Simple (HMO) covers emergency services for a $130 copay and urgently needed services for a $20 copay, both with no coinsurance and with copays waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent services are partially covered up to a $50,000 maximum with a $130 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple (HMO) covers primary care visits with no copay and no coinsurance, and specialist visits with a $15 copay and no coinsurance. Physical and occupational therapies require a $20 copay, mental health services have a $25 copay, and telehealth ranges from $0 to $25, all with no coinsurance, while podiatry is not covered and chiropractic care is partially covered with routine and other chiropractic services excluded.
Preventive Services See details
Preventive services under Wellcare Simple (HMO) are partially covered, offering annual physical exams, alternative therapies, and memory fitness benefits with no copays and no coinsurance. While kidney disease education is covered with no copay and a 20% coinsurance, several supplemental services such as health education, nutritional/dietary benefits, and in-home safety assessments are not covered.
Hearing Services See details
Wellcare Simple (HMO) provides partially covered hearing services, featuring routine exams and fitting evaluations with no copay and no coinsurance, and Medicare-covered exams for a $15 copay and no coinsurance. While prescription hearing aids are covered up to $500 per ear annually with no copay and no coinsurance, OTC hearing aids as well as inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Wellcare Simple (HMO) partially covers vision services with no deductibles and no coinsurance, though other eye exam services are not covered. Routine eye exams and eyewear have no copay, with eyewear covered up to a $100 annual limit, while other covered eye exams have a copay of $0 to $15.
Dental Services See details
Wellcare Simple (HMO) provides partially covered dental services, featuring Medicare-covered dental for a $15 copay and no coinsurance, as well as preventive and comprehensive services with no copay and no coinsurance up to a $2,000 annual limit. Although many restorative and surgical services are included, maxillofacial prosthetics, implant services, and orthodontics are not covered by the plan.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Wellcare Simple (HMO) with no copay, though prior authorization and step therapy are required. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Wellcare Simple (HMO) covers durable medical equipment (DME), prosthetics, and medical supplies with no copay and a 20% coinsurance. Covered diabetic supplies have no copay, while diabetic therapeutic shoes and inserts require a 20% coinsurance, with prior authorization required for these medical equipment benefits.
Diagnostic and Radiological Services See details
Wellcare Simple (HMO) covers diagnostic services with no coinsurance, featuring no copay for lab services and copays ranging from $0 to $50 for diagnostic procedures. Covered radiological services require no copay for diagnostic radiology, a 20% coinsurance for therapeutic radiology, and a $50 copay for outpatient X-rays, with prior authorization required for both categories of services.
Home Health Services See details
Home health services are covered under Wellcare Simple (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Wellcare Simple (HMO) does not cover Cardiac Rehabilitation Services in practice, as cardiac, intensive cardiac, pulmonary, and SET for PAD services are all not covered and carry copays ranging from $25 to $50. The plan otherwise features no coinsurance for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Wellcare Simple (HMO) with no coinsurance, requiring prior authorization and allowing admission without a prior three-day inpatient hospital stay. There is no copay for days 1 to 20 and days 51 to 100, but a $218 daily copay applies for days 21 to 50, with additional days beyond the Medicare-covered 100-day limit not covered.
Other Services See details
Wellcare Simple (HMO) provides partial coverage for other services, offering over-the-counter (OTC) items and chronic illness meal benefits with no copay and no coinsurance. Acupuncture is not covered under this benefit, and a referral is required to receive the meal benefit.
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