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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 $1000.00 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 you meet your deductible, you will pay the following costs for drugs in each tier until your total drug costs reach $2000. For Tier 1 (Preferred Generic) and Tier 5 (Specialty Tier) drugs, there is no copay at preferred or standard pharmacies, and no copay for mail order. For Tier 2 (Standard Generic) drugs, you will pay 25% coinsurance. For Tier 3 (Preferred Brand) drugs, you will pay 32% coinsurance at a preferred pharmacy, and 33% at a standard pharmacy. For Tier 4 (Non-Preferred Drug) drugs, you will pay 28% coinsurance.
Additional Benefits
The Wellcare Simple Focus (HMO) plan offers a range of benefits with varying costs. For hospital stays, you'll pay a copay depending on the service and length of stay, with no copay for many days. Outpatient services have copays that vary, while services like primary care, hearing exams, vision services, and many dental services have no copay. This plan also includes coverage for ambulance, emergency, and transportation services with copays, as well as preventive services with no copay for annual exams. Additionally, you can receive home health services, and skilled nursing facility care. However, some services, like cardiac rehabilitation, and certain medical equipment, may require coinsurance or have associated fees.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. Inpatient Hospital-Acute has a $200 copay for days 1-4 and no copay for days 5-90, while Inpatient Hospital Psychiatric has a $150 copay for days 1-4 and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered with no copay for days 91-100. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, as well as additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric, are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered. Outpatient Hospital Services have a copay between $0 and $200, Observation Services have a copay between $140 and $200, Ambulatory Surgical Center (ASC) Services have no copay, Outpatient Substance Abuse Services have a $25 copay for both Individual and Group Sessions, and Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple Focus (HMO) plan, but requires prior authorization and a doctor's referral. You will have a $130 copay for this service.
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 $150 copay, while transportation services to a plan-approved health-related location have no copay for up to 24 one-way trips per year via rideshare, bus/subway, or medical transport. 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 by the Wellcare Simple Focus (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay and no coinsurance, while Urgently Needed Services have no copay and no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care benefits include no copay for Primary Care Physician Services, Chiropractic Services, and Routine Chiropractic Care, with the latter limited to 36 visits per year. Occupational Therapy Services, Physician Specialist Services, Physical Therapy, and Speech-Language Pathology Services have a $0 copay. Mental Health Specialty Services, Psychiatric Services, and Podiatry Services have a $25 copay for individual and group sessions. Additional Telehealth Benefits have a copay between $0 and $25, while Opioid Treatment Program Services have no 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, and some services require a copay. Kidney Disease Education Services are covered with 20% coinsurance. Other preventive services are covered, including glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit, all with no copay.
Hearing Services See details
The Wellcare Simple Focus (HMO) plan covers hearing exams with no copay, including routine hearing exams and fitting/evaluation for hearing aids, and covers up to $1,000 per year for prescription hearing aids with no copay. Prescription hearing aids - inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. There is no copay for eye exams, routine eye exams, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Eyewear has a combined maximum plan benefit coverage of $200 per year.
Dental Services See details
Dental services include Medicare dental services, oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, orthodontics, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), oral and maxillofacial surgery, and orthodontics. Oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatment have no copay. Other diagnostic dental services have a $15 copay, and other preventive dental services have a copay between $0 and $55. Restorative services have a copay between $0 and $300, adjunctive general services have a copay between $0 and $125, endodontics have a copay between $5 and $275, periodontics have a copay between $0 and $375, prosthodontics (removable) have a copay between $70 and $250, prosthodontics (fixed) have a copay between $0 and $225, oral and maxillofacial surgery have a copay between $0 and $70, and orthodontics have 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, and prior authorization is required. The plan covers Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple Focus (HMO) plan, but a doctor's 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 varying copays and 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 and a doctor referral required. Diagnostic Procedures/Tests and Lab Services have no copay, while Diagnostic Radiological Services have a copay of at most $50, Therapeutic Radiological Services have a coinsurance of at most 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 not covered by the Wellcare Simple Focus (HMO) plan. This includes 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.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple Focus (HMO) plan, but require prior authorization and a doctor's referral. For days 1-20, there is no copay, for days 21-30, the copay is $214, and for days 31-100, there is no copay. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes acupuncture and over-the-counter (OTC) items. Acupuncture has no copay and is limited to 36 treatments per year, while OTC items have no copay with a maximum plan benefit coverage amount of $76.00 every three months. Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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