Wellcare Simple Focus (HMO-POS)

Inpatient Hospital See details

Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $362 copay for days 1-7, and no copay for days 8-90, while for Inpatient Hospital Psychiatric, you will pay a $290 copay for days 1-7, and no copay for days 8-90. Additional Days for Inpatient Hospital-Acute are covered with no copay for days 91-120, and Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are also not covered.

Outpatient Services See details

Outpatient Services include coverage for outpatient hospital services with a copay of $0-$375, observation services with a copay of $110-$375, ambulatory surgical center services with a $250 copay, outpatient substance abuse services with a $25 copay for individual and group sessions, and outpatient blood services with no copay. Prior authorization is required for some of these services.

Partial Hospitalization See details

Partial Hospitalization is covered by the Wellcare Simple Focus (HMO-POS) plan, but requires prior authorization. You will have a copay of $80 for this benefit.

Ambulance and Transportation Services See details

Ambulance and Transportation Services are covered by the Wellcare Simple Focus (HMO-POS) plan, including both ground and air ambulance services with a $310 copay and no coinsurance. 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-POS) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, while Urgently Needed Services have a $25 copay; all three have no coinsurance. Worldwide Emergency Transportation is not covered.

Primary Care See details

Wellcare Simple Focus (HMO-POS) covers Primary Care Physician Services with no copay. Chiropractic services have a $15 copay, while Occupational Therapy Services have a $20 copay.

Physician Specialist Services have a $20 copay, and Individual and Group Sessions for Mental Health Specialty Services each have a $25 copay.

Podiatry Services and Other Health Care Professional services have a $20 copay.

Physical Therapy and Speech-Language Pathology Services have a $20 copay, and Additional Telehealth Benefits have a copay between $0 and $25.

Opioid Treatment Program Services have a $20 copay.

Preventive Services See details

Preventive Services include coverage for Annual Physical Exams with no copay, and other preventive services with no copay for glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. Kidney Disease Education Services have a 20% coinsurance.

Hearing Services See details

Hearing Services include coverage for hearing exams with a $20 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a maximum plan benefit of $500 per year, and prescription hearing aids of all types are covered with no copay. Prescription hearing aids for the inner ear, outer ear, and over the ear, as well as OTC hearing aids, are not covered.

Vision Services See details

Wellcare Simple Focus (HMO-POS) covers vision services, including eye exams with a copay of $0-$20, and eyewear with no copay. The plan offers one routine eye exam per year with no copay. Eyewear has a combined maximum benefit of $100 per year.

Dental Services See details

Dental Services includes coverage for Medicare Dental Services with a $20 copay, Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, and Other Preventive Dental Services with no copay, and Adjunctive General Services with no copay. 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 under the Wellcare Simple Focus (HMO-POS) plan. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance is between 0% and 20%.

Dialysis Services See details

Dialysis Services are covered by the Wellcare Simple Focus (HMO-POS) plan. You will pay 20% coinsurance for these services.

Medical Equipment See details

The Wellcare Simple Focus (HMO-POS) plan covers Durable Medical Equipment (DME) with a 20% coinsurance, and Prosthetic Devices and Medical Supplies with a 20% coinsurance and no copay. Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Medical Equipment for use outside the home is not covered.

Diagnostic and Radiological Services See details

Diagnostic and Radiological Services are covered by the Wellcare Simple Focus (HMO-POS) plan. Diagnostic Procedures/Tests have a maximum copay of $75, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $300, Therapeutic Radiological Services have a minimum coinsurance of 20%, and Outpatient X-Ray Services have a copay of $80.

Home Health Services See details

Home Health Services are covered by the Wellcare Simple Focus (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 generally covered by the Wellcare Simple Focus (HMO-POS) plan, but the plan does not cover the specific services listed. There is a copay for covered services; however, the specific amount is not listed.

Skilled Nursing Facility (SNF) See details

Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple Focus (HMO-POS) plan, with prior authorization required. For days 1-20 and 61-100, there is no copay, while days 21-60 have a $214 copay.

Other Services See details

The Wellcare Simple Focus (HMO-POS) plan covers acupuncture with no copay, but requires prior authorization and is limited to 24 treatments per year. Other services like over-the-counter items, meal benefits, and many other services are not covered.