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Wellcare Simple Focus (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple Focus (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Simple Focus (HMO) in 2025, please refer to our full plan details page.
Wellcare Simple Focus (HMO) is a HMO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select counties in CA. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Wellcare Simple Focus (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 Focus (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 Focus (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 $4150.00 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 Focus (HMO) plan has a $420 deductible for prescription drugs. After the deductible is met, you will pay the following costs for your medications. For preferred generic drugs, you will have no copay at preferred pharmacies and preferred mail order, and a $10 copay at standard pharmacies and standard mail order. For standard generic drugs, you will pay 25% coinsurance regardless of the pharmacy. For preferred brand drugs, you will pay 38% coinsurance, and for non-preferred drugs, you will pay 28% coinsurance. Specialty tier drugs have no copay. 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 Focus (HMO) plan offers a wide range of benefits with varying costs. Inpatient hospital stays have copays depending on the length of stay, while outpatient services have copays from $0 to $350, and emergency services have a $140 copay. The plan also covers primary care with no copay, preventive services with no copay for many services, and hearing, vision, and dental services with copays that vary depending on the specific service. Other covered services include ambulance, home health, and skilled nursing facility services, as well as medical equipment, diagnostic and radiological services, and home infusion, all with varying cost sharing.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care. For acute care, you will pay a $250 copay for days 1-5, and no copay for days 6-90; additional days 91-100 have no copay. For psychiatric care, you will pay a $200 copay for days 1-5, and no copay for days 6-90. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $350, Observation Services with a copay between $140 and $350, Ambulatory Surgical Center (ASC) Services with a $250 copay, Outpatient Substance Abuse Services with a $25 copay, and Outpatient Blood Services with no copay. A doctor referral is required for all services, and prior authorization is required for Outpatient Hospital Services, Ambulatory Surgical Center (ASC) Services, and Outpatient Substance Abuse Services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple Focus (HMO) plan and requires prior authorization and a doctor referral. The copay for this benefit is $130.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Wellcare Simple Focus (HMO) plan. Ground and air ambulance services have a copay of $270, with no coinsurance, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Wellcare Simple Focus (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay with no coinsurance, and Urgently Needed Services have a $25 copay with no coinsurance. Worldwide Urgent Coverage also has a $140 copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services are covered with no copay. Chiropractic Services, including routine care, require a $5 copay, and a doctor referral and prior authorization. Occupational Therapy Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, and Opioid Treatment Program Services require a $5 copay. Mental Health Specialty Services, Psychiatric Services, and Additional Telehealth Benefits have varying copays. Podiatry Services and Other Health Care Professional have varying copays.
Preventive Services See details
Preventive Services are covered by the Wellcare Simple Focus (HMO) plan, including an annual physical exam with no copay. Additional preventive services, including Alternative Therapies, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, are covered with no copay, but some services require a referral.
Hearing Services See details
Hearing services include hearing exams with a $5 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, with a plan-specified amount of $500.00 per year. Prescription hearing aids - inner ear, outer ear, and over the ear are not covered, nor are OTC hearing aids.
Vision Services See details
Vision services are covered, including eye exams and eyewear. Eye exams have a copay of $0 to $5, while routine eye exams have no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, also have no copay, with a combined maximum benefit of $300 every year.
Dental Services See details
Dental services include coverage for Medicare dental services with a $5 copay, oral exams with no copay, and dental x-rays with no copay. Other diagnostic dental services have a $15 copay, and prophylaxis (cleaning), fluoride treatment, and other preventive dental services have copays that range from $0 to $55. Orthodontic services cover restorative, adjunctive general, endodontics, periodontics, prosthodontics, and oral and maxillofacial surgery with copays ranging from $0 to $375, while orthodontics has a copay that ranges from $0 to $2250. Maxillofacial prosthetics and implant services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. The plan covers Medicare Part B Insulin Drugs with a $35 copay, and covers Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple Focus (HMO) plan, but a doctor referral is required. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Wellcare Simple Focus (HMO) plan. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a copay up to $280.00, Therapeutic Radiological Services have a coinsurance of 20%, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple Focus (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 covered with a doctor referral, but 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. The plan does not specify the cost sharing for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization and a doctor's referral. There is no copay for days 1-20 and 41-100, but there is a $214 copay for days 21-40; there is no coinsurance. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services include acupuncture and over-the-counter (OTC) items. Acupuncture has no copay, but requires prior authorization and a doctor referral, with a limit of 24 treatments per year. OTC items also have no copay, with a maximum benefit coverage amount of $30 every three months. Some other services are not covered.
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