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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 no drug deductible. Your prescription medication coverage will start immediately.
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 $0 deductible for prescription drugs. During the initial coverage phase, you'll pay varying costs depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay, while standard generic drugs have 18-25% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. This plan also offers a Part D premium reduction for those who qualify for the low-income subsidy.
Additional Benefits
The Wellcare Simple Focus (HMO) plan offers comprehensive coverage with a variety of benefits. This plan includes no copays for primary care visits, many outpatient services, preventive services, vision, and dental exams, along with no copay for hearing exams, and home health services. You will pay a copay for inpatient hospital stays, emergency services, and some outpatient services. Additional benefits include coverage for ambulance and transportation services, with no copay for transportation to health-related locations. The plan also covers prescription hearing aids and offers coverage for over-the-counter items, including nicotine replacement therapy, and naloxone, and has a $100 annual eyewear allowance. Diagnostic and radiological services, including lab services, are covered with no copay.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, there is a $175 copay for days 1-4, and no copay for days 5-90, and for Inpatient Hospital Psychiatric services, there is a $125 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 91-120, with a limit of 30 additional days. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with copays ranging from $0 to $200 depending on the service, and for outpatient substance abuse services with a $25 copay for both individual and group sessions. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Wellcare Simple Focus (HMO) plan, but 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, with prior authorization required. Ground and air ambulance services have a $150 copay, and transportation services to a plan-approved health-related location have no copay, with 12 one-way trips allowed per year via rideshare services, bus/subway, or medical transport. Transportation services to any health-related location are not covered.
Emergency Services See details
The Wellcare Simple Focus (HMO) plan covers emergency services with a $140 copay and no coinsurance, and urgently needed services with no copay and no coinsurance. Worldwide emergency coverage and urgent coverage have a $140 copay, and 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. Additional benefits include no copay for Occupational Therapy Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, and Opioid Treatment Program Services. Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, and Psychiatric Services have a copay of $25 for individual and group sessions. Additional Telehealth Benefits have a copay between $0 and $25.
Preventive Services See details
The Wellcare Simple Focus (HMO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services such as alternative therapies, glaucoma screening, and diabetes self-management training are also covered 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, each limited to one visit per year. Prescription hearing aids are covered, but the plan does not cover prescription hearing aids for the inner ear, outer ear, and over the ear, and does not cover OTC hearing aids.
Vision Services See details
Vision services, including eye exams and eyewear, are covered by the Wellcare Simple Focus (HMO) plan. Eye exams and eyewear have no copay, and eyewear has a combined maximum benefit of $100 per year.
Dental Services See details
Dental Services include coverage for Medicare dental services with no copay, and other dental services including oral exams and dental x-rays with no copay, Other diagnostic dental services with a $15 copay, prophylaxis (cleaning) with no copay, fluoride treatment with no copay, and other preventive dental services with a copay between $0 and $55. Orthodontic services include coverage for 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, prosthodontics (removable) 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; however, maxillofacial prosthetics and implant services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple Focus (HMO) plan, and require a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and prior authorization, and Prosthetics/Medical Supplies with 20% coinsurance, while Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures, lab services, and radiological services, are covered. Diagnostic Procedures/Tests have no copay, and Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $50, and Therapeutic Radiological Services have coinsurance of at least 20%. Outpatient X-Ray Services have no 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, but the plan does not cover any of the listed sub-services. A doctor's referral is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Wellcare Simple Focus (HMO) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20 and days 31-100, but there is a $214 copay for days 21-30. Additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Wellcare Simple Focus (HMO) plan covers acupuncture with no copay, but requires prior authorization and a doctor referral, and is limited to 36 treatments per year. Over-the-counter (OTC) items are covered with no copay, and have a maximum benefit coverage amount of $75 every three months, and includes nicotine replacement therapy and naloxone coverage. Other services, including meal benefits, are not covered.
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