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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) plan features an annual prescription drug deductible of $615. For Tier 1 (Preferred Generic) and Tier 2 (Generic) medications, members pay no copay when using preferred pharmacies or preferred mail-order services. Additionally, Tier 6 (Select Care Drugs) are available with no copay across all standard and preferred pharmacies and mail-order options. For higher-tier prescriptions, the plan utilizes coinsurance rather than flat copays, charging 25% coinsurance for both Tier 3 (Preferred Brand) and Tier 5 (Specialty Tier) drugs. Tier 4 (Non-Preferred Drug) medications require a 35% coinsurance payment regardless of the pharmacy type. Standard pharmacies and standard mail-order services are also available for generic tiers, with copays starting at $5 for Tier 1 and $10 for Tier 2.
Additional Benefits
The Wellcare Simple (HMO) plan offers comprehensive coverage with predictable costs, featuring no copay for primary care visits, routine physical exams, and home health services. Specialists, physical therapy, and mental health services require low copays ranging from $20 to $25, while emergency room visits have a $150 copay. Inpatient hospital stays and skilled nursing facility care require daily copays for certain days, but feature no copay for the remaining covered days. Additionally, members enjoy routine dental, vision, and hearing services with no copay, including allowances of up to $2,000 for dental care and $1,000 per ear for hearing aids. Over-the-counter items, diabetic supplies, and diagnostic lab services are also covered with no copay. For durable medical equipment, dialysis, and chemotherapy drugs, the plan features no copay and up to a 20% coinsurance.
Inpatient Hospital See details
Wellcare Simple (HMO) partially covers inpatient hospital services with no coinsurance, though prior authorization is required. For acute stays, there is a $325 daily copay for days 1-6 and no copay for days 7-90, while psychiatric stays require a $237 daily copay for days 1-7 and no copay for days 8-90; additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Wellcare Simple (HMO) covers outpatient services with no coinsurance, including outpatient hospital services with a copay ranging from $0 to $280 and ambulatory surgical center services with a $150 copay. Outpatient substance abuse sessions require a $25 copay and no coinsurance, while outpatient blood services are covered with no copay, coinsurance, or deductible.
Partial Hospitalization See details
Partial hospitalization is covered by Wellcare Simple (HMO) 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 and no coinsurance, requiring prior authorization. Transportation services are partially covered with no copay or coinsurance for up to 12 one-way trips per year to plan-approved locations, while transportation to any health-related location is 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 $30 copay and no coinsurance, with copays waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent services are partially covered up to a $50,000 benefit limit with a $150 copay and no coinsurance, but 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 $20 copay and no coinsurance. Mental health and psychiatric services have a $25 copay and no coinsurance, though podiatry is not covered, and some chiropractic services are covered but routine and other chiropractic services are not.
Preventive Services See details
Wellcare Simple (HMO) preventive services are partially covered, offering annual physical exams, fitness benefits, and various screenings with no copay and no coinsurance, while kidney disease education has no copay and a 20% coinsurance. Specific supplemental services, including health education, personal emergency response systems, and weight management programs, are not covered.
Hearing Services See details
Wellcare Simple (HMO) covers Medicare-covered hearing exams with a $20 copay and no coinsurance, while routine exams and fitting evaluations are fully covered annually with no copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to a $1,000 maximum per ear each year, though inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Wellcare Simple (HMO) vision services are partially covered, offering one annual routine eye exam with no copay and no coinsurance, though other eye exam services are not covered. Eyewear, including glasses and contacts, is covered with no copay or coinsurance up to a $200 annual maximum, while other covered eye exams require prior authorization and have a copay of $0 to $20.
Dental Services See details
Wellcare Simple (HMO) provides partially covered dental services, featuring a $20 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered preventive and comprehensive services up to a $2,000 annual maximum. 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 and no coinsurance, though prior authorization is required. Covered Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have 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
Wellcare Simple (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance. Diabetic supplies are covered with no copay, and diabetic therapeutic shoes and inserts require a 20% coinsurance, with prior authorization required for these services.
Diagnostic and Radiological Services See details
Wellcare Simple (HMO) covers diagnostic and radiological services with prior authorization, offering diagnostic lab services with no copay and no coinsurance. Diagnostic procedures and tests carry a copay of $0 to $95 with no coinsurance, while outpatient X-rays require a $50 copay and therapeutic radiological services have a minimum 20% coinsurance.
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
Wellcare Simple (HMO) covers some cardiac rehabilitation services with no coinsurance, though standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered under the plan.
Skilled Nursing Facility (SNF) See details
Wellcare Simple (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization and allowing admission without a prior three-day hospital stay. There is no copay for days 1 to 20 and days 41 to 100, but a $218 daily copay applies for days 21 to 40, and additional days beyond the standard Medicare-covered limit are 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, though a referral is required for meals. Acupuncture and other miscellaneous services under this benefit are not covered.
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