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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 $3400.00 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 Tier 1 (Preferred Generic) and Tier 5 (Specialty Tier) drugs, there is no copay at preferred pharmacies. For Tier 2 (Standard Generic), Tier 3 (Preferred Brand), and Tier 4 (Non-Preferred Drug) drugs, you will pay coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Wellcare Simple (HMO) plan offers a range of benefits, including coverage for inpatient hospital stays with a copay, outpatient services with varying copays, and partial hospitalization with a $130 copay. Additionally, this plan covers ambulance services, emergency services, and primary care services with no copay for many services. This plan also includes preventive services like annual physical exams and routine hearing exams with no copay, along with coverage for hearing aids, vision services, and dental services with no copay for most services. Other benefits include home health services with no copay, and medical equipment with a 20% coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $325 per day for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute; Inpatient Hospital Psychiatric has a copay of $237 per day for days 1-7 and no copay for days 8-90. Additional days and non-Medicare-covered stays for both acute and psychiatric care are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $280, and observation services with a copay between $140 and $280. Ambulatory Surgical Center (ASC) Services have a $150 copay, and outpatient substance abuse services have a $25 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. The copay for this benefit is $130.
Ambulance and Transportation Services See details
Ambulance and Transportation Services includes coverage for ground and air ambulance services with a $250 copay, and transportation services to a plan-approved health-related location with no copay for up to 12 one-way trips per year. Transportation services to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Wellcare Simple (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay, while Urgently Needed Services have a $30 copay, and all have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
Wellcare Simple (HMO) covers primary care physician services with no copay, while chiropractic services have a $20 copay. Occupational therapy services have a $20 copay and no coinsurance, and physician specialist services have a $20 copay. Mental health specialty services and psychiatric services have a $25 copay for both individual and group sessions, and physical therapy and speech-language pathology services have a $20 copay and no coinsurance. Additional telehealth benefits have a copay between $0 and $30, and opioid treatment program services have a $20 copay.
Preventive Services See details
The Wellcare Simple (HMO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services include Fitness Benefit, Alternative Therapies, and Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) with no copay. Kidney Disease Education Services have a 20% coinsurance. Other preventive services include Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay. However, 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
Wellcare Simple (HMO) covers hearing exams with a $20 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. This plan also covers prescription hearing aids, with a maximum benefit of $750 per year. Prescription hearing aids for the inner, outer, and over the ear are not covered, nor are OTC hearing aids.
Vision Services See details
Vision Services include eye exams with a copay of $0-$20, and eyewear with no copay. Eyewear includes coverage for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades with a combined maximum benefit of $100 per year.
Dental Services See details
The Wellcare Simple (HMO) plan covers dental services, including 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 for most services. Orthodontic services are covered up to a maximum of $2,000 per year. However, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay. 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 a coinsurance of 20% for these services.
Medical Equipment See details
The Wellcare Simple (HMO) plan covers Durable Medical Equipment (DME) with 20% coinsurance, and Prosthetic Devices and Medical Supplies with 20% coinsurance. Diabetic Supplies are covered with no copay, and 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 copay between $0 and $95, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $225. Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $75 copay.
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. While Cardiac Rehabilitation Services are technically covered, the plan does not cover any of the sub-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 21-40, the copay is $214, and for days 41-100, there is no copay. Additional days beyond Medicare-covered SNF stays and non-Medicare-covered stays are not covered.
Other Services See details
The Wellcare Simple (HMO) plan covers Over-the-Counter (OTC) items with no copay, up to a maximum of $79 every three months. However, acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and many other services are not covered.
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