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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 $6750.00 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 a copay or coinsurance for your prescriptions, depending on the drug tier and the pharmacy you use. For preferred generic drugs, there is no copay at preferred pharmacies and mail order pharmacies, and a $10 copay at standard pharmacies. For specialty tier drugs, there is no copay at any pharmacy.
Additional Benefits
The Wellcare Simple Focus (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $350 copay for the first five days, then no copay, while outpatient services have copays between $0 and $250. Many services have no copay, including primary care, hearing exams, vision, and dental exams. This plan also covers ambulance services with a $275 copay and offers no copay for transportation to health-related locations. Preventive services like annual physicals have no copay, but other services like hearing aids, vision, and dental have copays. Additionally, the plan provides coverage for home health, skilled nursing, and other services like acupuncture and over-the-counter items, with varying cost-sharing arrangements.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For days 1-5, there is a $350 copay, and for days 6-90, there is no copay. Additional days for inpatient hospital and non-Medicare-covered stays are not covered.
Outpatient Services See details
The Wellcare Simple Focus (HMO) plan covers outpatient services, including outpatient hospital services with a copay between $0 and $250, and observation services with a copay between $125 and $250. The plan also covers ambulatory surgical center services with a $200 copay, outpatient substance abuse services with a $25 copay for individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple Focus (HMO) plan, with a $105 copay. Prior authorization and a doctor referral are required to receive this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, including ground and air ambulance, are covered by the Wellcare Simple Focus (HMO) plan. Ground and air ambulance services have a copay of $275, while transportation services to a plan-approved health-related location have no copay for up to 12 one-way trips per year, using rideshare services, bus/subway, or medical transport.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered by the Wellcare Simple Focus (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services has a $25 copay, and there is no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Primary Care Physician Services, Chiropractic Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, and Additional Telehealth Benefits have no copay. Individual and Group Mental Health and Psychiatric Sessions have a $25 copay.
Preventive Services See details
The Wellcare Simple Focus (HMO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services are covered, but a copay is required for fitness benefits, remote access technologies, and alternative therapies. Kidney disease education services are covered with 20% coinsurance. Some other preventive services, such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit, are covered with no copay.
Hearing Services See details
Wellcare Simple Focus (HMO) covers hearing exams with no copay, routine hearing exams with no copay for one visit per year, and fitting/evaluation for hearing aids with no copay for one visit per year. Prescription hearing aids are covered with a maximum plan benefit of $500 per year, with no copay for two visits per year for all types of hearing aids, but inner, outer, and over the ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The Wellcare Simple Focus (HMO) plan covers vision services, including eye exams and eyewear. Eye exams and eyewear have no copay. Eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades have no copay. Contact lenses have no copay. Eyewear has a combined maximum of $200 per year.
Dental Services See details
Dental services include coverage for Medicare dental services with no copay, oral exams with no copay, and dental x-rays with no copay. Other diagnostic dental services have a $15 copay, while prophylaxis (cleaning) and fluoride treatment have no copay. Other preventive dental services have a copay between $0 and $55. Orthodontic services include restorative services with a copay between $0 and $300, adjunctive general services with a copay between $0 and $125, endodontics with a copay between $5 and $275, periodontics with a copay between $0 and $375, removable prosthodontics with a copay between $70 and $250, prosthodontics fixed with a copay between $0 and $225, oral and maxillofacial surgery with a copay between $0 and $70, and orthodontics with a copay between $0 and $2250. Maxillofacial prosthetics and implant services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and other Medicare Part B drugs, as well as Medicare Part B Chemotherapy/Radiation Drugs with coinsurance between 0% and 20%. Prior authorization is required for these benefits.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple Focus (HMO) plan, but a doctor referral is required. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Equipment, with a 20% coinsurance for Diabetic Therapeutic Shoes/Inserts and no copay for Diabetic Supplies. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, lab services, and radiological services. Diagnostic Procedures/Tests have a copay between $0 and $25, while Lab Services have no copay. Diagnostic Radiological Services have a copay up to $250 and Therapeutic Radiological Services have a 20% coinsurance, while 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 not covered by the Wellcare Simple Focus (HMO) plan. A doctor referral is required for Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Wellcare Simple Focus (HMO) plan. There is no copay for days 1-20 and 71-100, but there is a $214 copay for days 21-70.
Other Services See details
Under the Wellcare Simple Focus (HMO) plan, acupuncture has no copay and is limited to 24 treatments per year, but requires prior authorization and a doctor referral. Over-the-counter items are covered with no copay, and have a maximum plan benefit coverage amount of $36 every three months.
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