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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 $2000.00 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 drug benefit with a $615.00 prescription drug deductible. Individuals qualifying for the low-income subsidy (Extra Help) will see their Part D cost reduced to $0.00. After meeting your deductible, you will transition to the catastrophic coverage phase once your yearly out-of-pocket drug costs reach $2,100.00, after which you pay nothing for covered Part D drugs. During the initial coverage phase, Tier 1 preferred generics have no copay at preferred pharmacies and a $10.00 copay at standard pharmacies, while Tier 5 specialty drugs have no copay at either pharmacy type. Tier 2 standard generics and Tier 4 non-preferred drugs both require a 25% coinsurance at preferred and standard pharmacies. Tier 3 preferred brand drugs require a 37% coinsurance at both preferred and standard pharmacies.
Additional Benefits
The Wellcare Simple Focus (HMO) plan offers robust coverage with no copay and no coinsurance for primary care visits, specialist consultations, and routine preventive services. For hospital stays, members pay daily copays with no coinsurance, including a $200 daily copay for the first four days of acute inpatient care and no copay for subsequent days. Emergency room visits require a $150 copay, while urgent care services are available with no copay or coinsurance. Routine dental, vision, and hearing exams are covered with no copay or coinsurance, alongside annual allowances for eyewear and hearing aids. For durable medical equipment and dialysis services, members will pay a 20% coinsurance and no copay, though essential diabetic supplies are covered with no copay. Home health services and laboratory tests are also highly accessible, requiring no copay or coinsurance for plan members.
Inpatient Hospital See details
Wellcare Simple Focus (HMO) partially covers inpatient hospital services with no coinsurance, requiring a $200 daily copay for days 1 to 4 of acute stays (no copay for days 5 to 120) and a $150 daily copay for days 1 to 4 of psychiatric stays (no copay for days 5 to 90). Prior authorization and doctor referrals are required, while upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Wellcare Simple Focus (HMO) covers outpatient services with no coinsurance, including no copay for ambulatory surgical center and outpatient blood services. Other covered benefits require copays, such as $25 for outpatient substance abuse sessions, $150 to $200 per stay for observation services, and $0 to $200 for outpatient hospital services.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Wellcare Simple Focus (HMO) with a $175 copay and no coinsurance. Prior authorization and a doctor referral are required to receive these services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by Wellcare Simple Focus (HMO), which features a $300 copay and no coinsurance for both ground and air ambulance services, subject to prior authorization. However, transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Wellcare Simple Focus (HMO) covers emergency services with a $150 copay and no coinsurance, and urgently needed services with no copay or coinsurance. Worldwide emergency and urgent care are partially covered up to a $50,000 lifetime limit with a $150 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Primary Care benefits are partially covered by Wellcare Simple Focus (HMO) because podiatry services are not covered. Most covered services, including primary care and specialist visits, feature no copay and no coinsurance, while mental health and psychiatric sessions require a $25 copay and no coinsurance.
Preventive Services See details
Preventive services are partially covered by Wellcare Simple Focus (HMO), offering annual physicals, fitness benefits, and screenings with no copay and no coinsurance, while kidney disease education requires a 20% coinsurance and no copay. Several supplemental services are not covered, including health education, weight management, personal emergency response systems, in-home safety assessments, and therapeutic massage.
Hearing Services See details
Hearing services are partially covered by Wellcare Simple Focus (HMO), offering annual routine exams and fitting evaluations with no copays, no coinsurance, and no deductible. Prescription hearing aids are covered with no copay or coinsurance up to a $350 annual maximum per ear, but OTC hearing aids as well as inner-ear, outer-ear, and over-the-ear prescription models are not covered.
Vision Services See details
Vision services are covered by Wellcare Simple Focus (HMO) with no copay and no coinsurance, including one routine eye exam per year and eyewear such as contacts and glasses. Prior authorization is required, and there is a combined maximum plan benefit of $100 every year for eyewear.
Dental Services See details
Wellcare Simple Focus (HMO) partially covers dental services with copays ranging from no copay up to $2,250 and no coinsurance. While preventive, diagnostic, restorative, and orthodontic treatments are covered, maxillofacial prosthetics and implant services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Wellcare Simple Focus (HMO) with prior authorization required and step therapy rules applying. Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple Focus (HMO) plan with a 20% coinsurance and no copay. A doctor referral is required to receive these covered services.
Medical Equipment See details
Medical equipment is covered by Wellcare Simple Focus (HMO), with durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes requiring a 20% coinsurance and no copay. Diabetic supplies are covered with no copay and no coinsurance, though prior authorization is required for most medical equipment and supplies.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Wellcare Simple Focus (HMO), requiring prior authorization and doctor referrals. Members pay no copay and no coinsurance for lab services, outpatient X-rays, and diagnostic tests, while diagnostic radiological services carry a copay of up to $50 with no coinsurance, and therapeutic radiological services require 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) indicates that some services are covered, but Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Wellcare Simple Focus (HMO), as additional days beyond Medicare-covered care are not covered. This benefit features no coinsurance, with no copay for days 1 through 20 and days 31 through 100, and a $218 daily copay for days 21 through 30.
Other Services See details
Other Services are partially covered by Wellcare Simple Focus (HMO), featuring acupuncture with no copay and no coinsurance for up to 12 treatments per year with prior authorization and a doctor referral. However, over-the-counter (OTC) items, meal benefits, and highly integrated dual-eligible SNP services are not covered.
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