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Wellcare Simple (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Simple (HMO-POS) in 2025, please refer to our full plan details page.
Wellcare Simple (HMO-POS) is a HMO-POS plan offered by Centene Corporation available for enrollment in 2025 to people living in Select Counties in NJ. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Wellcare Simple (HMO-POS) 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 (HMO-POS).
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 (HMO-POS), 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 $8300.00 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 (HMO-POS) plan has a $420 deductible for prescription drugs. Once you meet your deductible, you will pay the following costs for your prescriptions. For preferred generic drugs, you will have no copay at preferred pharmacies and mail order, and a $10 copay at standard pharmacies. Standard generic drugs have 25% coinsurance, while preferred brand drugs have 34-35% coinsurance. Non-preferred drugs have 28% coinsurance, and specialty tier drugs have no copay.
Additional Benefits
The Wellcare Simple (HMO-POS) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services involve copays and coinsurance depending on the specific service. You'll find no copays for primary care visits, annual physical exams, and many preventive, hearing, vision, and dental services. The plan also covers ambulance services with a copay, and offers emergency services with a $110 copay. Additionally, services like home health, skilled nursing facilities, and certain diagnostic and home infusion services are covered with varying copays and coinsurance. However, cardiac rehabilitation, certain "other" services, and additional hours of care are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $435 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, there is a $1850 copay for a Medicare-covered stay. Additional days, non-Medicare-covered stays, and upgrades for both services are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a 30% coinsurance and a copay between $0 and $400, and observation services with a 30% coinsurance and a $110 copay. Ambulatory Surgical Center (ASC) Services have a $250 copay, and Outpatient Substance Abuse Services have a $25 copay for both individual and group sessions. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple (HMO-POS) plan, but requires prior authorization. You will pay an $80 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Wellcare Simple (HMO-POS) plan. Ground and Air Ambulance Services have a $270 copay, with no coinsurance, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Coverage and Worldwide Urgent Coverage, are covered by the Wellcare Simple (HMO-POS) plan with a $110 copay and no coinsurance; Urgently Needed Services have a $25 copay and no coinsurance. Worldwide Emergency Transportation is not covered, and Worldwide Emergency Services have a maximum plan benefit coverage of $50,000.
Primary Care See details
The Wellcare Simple (HMO-POS) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, and occupational therapy services with a $35 copay. Also covered are physician specialist services with a $25 copay, mental health specialty services with a $25 copay, and physical therapy and speech-language pathology services with a $35 copay. Additionally, other telehealth benefits have a copay that ranges from $0 to $35.
Preventive Services See details
The Wellcare Simple (HMO-POS) plan covers preventive services, including an annual physical exam with no copay, and additional preventive services with a copay for some services. Kidney disease education services have a 20% coinsurance, while glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit have no copay.
Hearing Services See details
The Wellcare Simple (HMO-POS) plan covers hearing exams with a $25 copay. Routine hearing exams and fitting/evaluation for hearing aids are covered with no copay. Prescription hearing aids are covered, with a maximum benefit of $350 per year and 2 visits per year with no copay for prescription hearing aids (all types).
Vision Services See details
The Wellcare Simple (HMO-POS) plan covers vision services including eye exams and eyewear. Eye exams have a copay of $0-$25, and routine eye exams have no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, have no copay, with a combined maximum benefit of $100 per year.
Dental Services See details
The Wellcare Simple (HMO-POS) plan covers Medicare Dental Services with a $25 copay and no coinsurance. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatments, other preventive dental services, and adjunctive general services are covered with no copay and no coinsurance; however, restorative services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Wellcare Simple (HMO-POS) plan. 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 (HMO-POS) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance for Medicare-covered items, plus Diabetic Equipment. Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures and tests with a copay between $0 and $40, and lab services with no copay. This benefit also includes coverage for diagnostic radiological services with a copay up to $400, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with a $75 copay.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple (HMO-POS) 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 (HMO-POS) plan. The plan does not cover any of the sub-services that fall under Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Wellcare Simple (HMO-POS) plan. For days 1-20, there is no copay; for days 21-70, the copay is $214; and for days 71-100, there is no copay. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services are not covered by the Wellcare Simple (HMO-POS) plan. Specific services like acupuncture, over-the-counter items, meal benefits, and more are not covered.
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