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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 Texas. 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 $3800.00 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 type. For preferred generic drugs, you may have no copay or a $10 copay depending on the pharmacy. For standard generic drugs, the coinsurance is 25%. For preferred brand drugs, the coinsurance is 42%. The coinsurance for non-preferred drugs is 28%. Specialty tier drugs have no copay.
Additional Benefits
The Wellcare Simple (HMO) plan offers a range of benefits with varying cost-sharing. For hospital stays, you'll pay a copay that varies depending on the type of care and length of stay. Outpatient services have copays, and emergency services have a $140 copay. This plan covers a variety of services with no copay, including primary care, preventive services, routine vision and hearing exams, and home health services. There are also benefits for dental, hearing, and vision services, but they may have annual maximums. Other services such as home infusion, medical equipment, and dialysis have coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered under the Wellcare Simple (HMO) plan. For Inpatient Hospital-Acute, you'll pay a $350 copay for days 1-6, and no copay for days 7-90; for Inpatient Hospital Psychiatric, the copay is $275 for days 1-6, and no copay for days 7-90. Additional days, non-Medicare-covered stays, and upgrades for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $400, Observation Services with a copay between $140 and $400, Ambulatory Surgical Center (ASC) Services with a $250 copay, and Outpatient Substance Abuse Services with a $30 copay 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 service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a $250 copay for both ground and air ambulance services. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered under the Wellcare Simple (HMO) plan with a $140 copay, and no coinsurance. Urgently Needed Services have a $30 copay and no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $140 copay and no coinsurance, while 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, and Occupational Therapy Services with a $30 copay. This plan also covers Physician Specialist Services with a $25 copay, Mental Health Specialty Services with a $30 copay for individual and group sessions, and Physical Therapy and Speech-Language Pathology Services with a $30 copay. Additional Telehealth Benefits are covered with a copay between $0 and $30, and Opioid Treatment Program Services have a $25 copay.
Preventive Services See details
The Wellcare Simple (HMO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, as well as glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit, are covered with no copay. Kidney disease education services have a 20% coinsurance. Some preventive services, such as health education, in-home safety assessments, personal emergency response systems, and others are not covered.
Hearing Services See details
Wellcare Simple (HMO) covers hearing exams with a $25 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 ear every year, and OTC hearing aids are not covered.
Vision Services See details
Wellcare Simple (HMO) covers vision services, including eye exams with a copay between $0 and $25, and eyewear such as contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades with no copay, but with a combined maximum benefit of $200 per year. Routine eye exams are covered with no copay, with one exam covered every year.
Dental Services See details
Dental services include coverage for Medicare Dental Services with a $25 copay, while 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 all have no copay. Orthodontic services are covered up to a maximum of $2,000 per year. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Wellcare Simple (HMO) plan, and prior authorization is required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME) and Prosthetics/Medical Supplies, is covered by the Wellcare Simple (HMO) plan. Durable Medical Equipment has a 20% coinsurance, and Prosthetic Devices and Medical Supplies have a 20% coinsurance, while Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a copay between $0 and $30, lab services with no copay, diagnostic radiological services with a copay up to $350, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with a $75 copay. Prior authorization is required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple (HMO) plan with no copay and no coinsurance. 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 any of the sub-services, including Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Wellcare Simple (HMO) plan, but require prior authorization. For days 1-20, there is no copay, for days 21-50, there is a $214 copay, and for days 51-100, there is no copay.
Other Services See details
Under the Wellcare Simple (HMO) plan, Other Services include coverage for Over-the-Counter (OTC) Items with no copay, and a maximum benefit coverage amount of $58 every three months. Meal Benefits are also covered with no copay, but require a doctor's referral. 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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