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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 Texas. 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 $3900.00 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. For Tier 1 preferred generic, Tier 2 generic, and Tier 6 select care drugs, you will pay no copay when filling prescriptions through preferred pharmacies or preferred mail-order services. Standard pharmacies and standard mail-order options offer low copays starting at $5 for Tier 1 and $10 for Tier 2 medications. For brand-name and specialty medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs and Tier 5 specialty drugs require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 37% coinsurance. Specialty drugs under Tier 5 are limited to a 1-month supply at both preferred and standard pharmacies.
Additional Benefits
The Wellcare Simple (HMO) plan offers comprehensive coverage for essential medical services, featuring no copay and no coinsurance for primary care visits, annual physical exams, and home health services. For specialist visits, patients pay a $25 copay, while inpatient hospital stays require a daily copay of $350 for the first six days of acute care with no coinsurance. Emergency room visits carry a $150 copay, and urgent care services are available with a $30 copay, with both copays waived if you are admitted within 24 hours. This plan also includes routine dental, vision, and hearing care with no copay or coinsurance, offering annual allowances of $1,500 for dental services and $500 per ear for prescription hearing aids. Diagnostic lab services, diabetic supplies, and over-the-counter items are also covered with no copay. For other medical needs, patients will pay a 20% coinsurance for dialysis and durable medical equipment, while skilled nursing facility stays feature no copay for days 1 through 20.
Inpatient Hospital See details
Inpatient hospital care is partially covered by Wellcare Simple (HMO) with no coinsurance, requiring a $350 daily copay for days 1 through 6 of acute stays (no copay for days 7 through 95) and a $325 daily copay for days 1 through 6 of psychiatric stays (no copay for days 7 through 90). Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Wellcare Simple (HMO) covers outpatient hospital services with no coinsurance and a $0 to $400 copay, and observation services with a $150 to $400 copay per stay. Ambulatory surgical center services require a $200 copay with no coinsurance, outpatient substance abuse sessions have a $30 copay with no coinsurance, and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Wellcare Simple (HMO) with a $175.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Wellcare Simple (HMO) covers ground and air ambulance services with a $250 copay and no coinsurance per service, although prior authorization is required and the copay is not waived if you are admitted to the hospital. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Wellcare Simple (HMO) covers emergency services with a $150 copay and urgently needed services with a $30 copay, both with no coinsurance and copays waived if admitted within 24 hours. Worldwide emergency and urgent services are partially covered up to a $50,000 lifetime maximum with a $150 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple (HMO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $25 copay and no coinsurance. Physical, occupational, speech, mental health, and psychiatric therapies require a $30 copay and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services under the Wellcare Simple (HMO) plan are partially covered, featuring no copay and no coinsurance for annual physical exams, alternative therapies, fitness benefits, remote access, and various screenings. While kidney disease education requires a 20% coinsurance with no copay, other options like health education, nutritional/dietary benefits, personal emergency response systems, and in-home safety assessments are not covered.
Hearing Services See details
Hearing services are partially covered by Wellcare Simple (HMO), offering Medicare-covered exams for a $25 copay and no coinsurance, alongside annual routine exams and fitting evaluations with no copay or coinsurance. Prescription hearing aids are covered up to $500 per ear annually with no copay or coinsurance, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
Vision services under Wellcare Simple (HMO) are partially covered, featuring no copay and no coinsurance for routine eye exams and eyewear, though other eye exam services are not covered. The plan offers a $200 annual maximum benefit for eyewear, including contacts and eyeglasses, with no deductible required.
Dental Services See details
Wellcare Simple (HMO) partially covers dental services, featuring a $25 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered preventive and comprehensive services up to a $1,500 annual limit. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Wellcare Simple (HMO) with no copay, subject to prior authorization and step therapy. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other Part B drugs feature no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Wellcare Simple (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Wellcare Simple (HMO) with no copay and a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes or inserts. Diabetic supplies are covered with no copay, and prior authorization is required for these benefits.
Diagnostic and Radiological Services See details
Wellcare Simple (HMO) covers diagnostic and radiological services with prior authorization, featuring diagnostic lab services at no copay and diagnostic procedures with a $0 to $30 copay under no coinsurance. Radiological services include outpatient X-rays for a $50 copay plus coinsurance, diagnostic radiology starting at no copay, and therapeutic radiology with a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered by Wellcare Simple (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are partially covered under Wellcare Simple (HMO) with no coinsurance, though several key sub-services are not covered. Specifically, standard cardiac rehabilitation ($50 copay), intensive cardiac rehabilitation ($65 copay), pulmonary rehabilitation ($40 copay), and supervised exercise therapy for symptomatic peripheral artery disease ($30 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Wellcare Simple (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and days 41 through 100, and a $218 daily copay for days 21 through 40. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard Medicare-covered days are not covered.
Other Services See details
Other services under the Wellcare Simple (HMO) are partially covered, featuring over-the-counter (OTC) items and chronic illness meal benefits with no copay and no coinsurance. Acupuncture is not covered under this plan, and a referral is required to receive the meal benefit.
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