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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 2026, 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 3.5 out of 5 stars in 2026.
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 $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 $4000.00 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 offers an Enhanced Alternative prescription drug benefit with a yearly drug deductible of $615.00. During the initial coverage phase, Tier 1 preferred generic drugs have no copay at preferred pharmacies and a $10.00 copay at standard pharmacies, while Tier 5 specialty drugs feature no copay at both pharmacy types. Other drug tiers, such as standard generics, preferred brands, and non-preferred drugs, require coinsurance payments ranging from 25% to 33% depending on the tier and pharmacy selected. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and will pay nothing for covered Medicare Part D drugs. Additionally, beneficiaries who qualify for the low-income subsidy, or Extra Help, can see their Part D premium reduced to $0.00. You should check the plan's formulary to confirm the exact tier and coverage details for your specific medications.
Additional Benefits
The Wellcare Simple Focus (HMO) plan offers robust coverage for essential medical services, featuring no copay and no coinsurance for primary care visits, specialist consultations, and routine preventive screenings. Inpatient hospital stays require a $300 daily copay for the first seven days, followed by no copay for days eight through 90. Emergency room visits and ambulance services carry a $150 copay with no coinsurance, while urgently needed services are available with no copay. Routine dental, vision, and hearing care are partially covered, with routine eye exams, hearing exams, and prescription hearing aids requiring no copay. For durable medical equipment and dialysis services, members will pay a 20% coinsurance with no copay, while home health services are covered with no copay. Please note that this plan does not cover acupuncture, over-the-counter items, or transportation services.
Inpatient Hospital See details
Inpatient hospital care is partially covered by Wellcare Simple Focus (HMO), requiring a $300 daily copay for days 1 through 7 and no copay or coinsurance for days 8 through 90. While acute care includes up to 10 additional days with no copay, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Wellcare Simple Focus (HMO) with no coinsurance, including ambulatory surgical center and outpatient blood services at no copay. Additionally, outpatient substance abuse sessions require a $25 copay, observation services require a $150 to $200 copay, and outpatient hospital services carry a $0 to $200 copay.
Partial Hospitalization See details
Partial hospitalization benefits are covered by the Wellcare Simple Focus (HMO) plan with a $175.00 copay and no coinsurance. Prior authorization and a doctor referral are required to receive these services.
Ambulance and Transportation Services See details
Wellcare Simple Focus (HMO) partially covers ambulance and transportation services, offering ground and air ambulance services for a $150 copay and no coinsurance, with prior authorization required. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Emergency services are covered under Wellcare Simple Focus (HMO) with a $150 copay and no coinsurance, while urgently needed services have no copay and no coinsurance. Worldwide emergency and urgent services are covered with a $150 copay up to a $50,000 limit, but worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple Focus (HMO) covers primary care, specialist, and therapy services with no copay and no coinsurance, while mental health, psychiatric, and telehealth services require copays up to $25 with no coinsurance. Podiatry is not covered, and chiropractic care is only partially covered, with routine chiropractic care excluded from coverage.
Preventive Services See details
Wellcare Simple Focus (HMO) partially covers preventive services, offering annual physicals, select screenings, and alternative therapies with no copay and no coinsurance, while kidney disease education requires a 20% coinsurance and no copay. Multiple supplemental services are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, and additional smoking cessation counseling.
Hearing Services See details
Hearing services are partially covered by Wellcare Simple Focus (HMO), offering routine exams, fitting evaluations, and prescription hearing aids with no copays or coinsurance. OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered, and there is a $350 annual maximum benefit per ear for covered prescription hearing aids.
Vision Services See details
Vision services are covered under Wellcare Simple Focus (HMO), including one annual routine eye exam and eyewear with a combined maximum benefit of $100 per year. These services require prior authorization and are available with no copay and no coinsurance.
Dental Services See details
Wellcare Simple Focus (HMO) partially covers dental services, with maxillofacial prosthetics and implant services excluded from coverage. Covered dental benefits require no coinsurance, with copays ranging from no copay up to $2,250 depending on the service.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Wellcare Simple Focus (HMO) and require prior authorization. Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while chemotherapy and other Part B drugs feature no copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered by Wellcare Simple Focus (HMO) with 20% coinsurance and no copay. A doctor referral is required to receive these covered services.
Medical Equipment See details
Wellcare Simple Focus (HMO) covers durable medical equipment, prosthetic devices, medical supplies, and diabetic therapeutic shoes with a 20% coinsurance and no copay. Diabetic supplies are covered with no copay and no coinsurance, though prior authorization is required for these benefits.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Wellcare Simple Focus (HMO) with prior authorization and doctor referrals. Diagnostic tests, procedures, and lab services have no copay or coinsurance, while diagnostic radiological services carry a copay of up to $50 with no coinsurance, outpatient X-rays require a $25 copay with no coinsurance, and therapeutic radiological services have a 20% coinsurance with no copay.
Home Health Services See details
Wellcare Simple Focus (HMO) covers home health services with no copay and no coinsurance. A doctor referral and prior authorization are required to receive these covered services.
Cardiac Rehabilitation Services See details
Wellcare Simple Focus (HMO) does not cover Cardiac Rehabilitation Services, as none of the sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are covered.
Skilled Nursing Facility (SNF) See details
Wellcare Simple Focus (HMO) partially covers Skilled Nursing Facility (SNF) benefits, as additional days beyond the Medicare-covered limit are not covered. There is no coinsurance, with cost-sharing requiring no copay for days 1 to 20 and 41 to 100, and a $218 copay for days 21 to 40.
Other Services See details
Other Services are not covered under the Wellcare Simple Focus (HMO) plan, meaning there is no coverage, copay, or coinsurance for acupuncture, over-the-counter (OTC) items, meal benefits, and dual eligible SNPs with highly integrated services.
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