Wellcare Simple (HMO)

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 $175 copay for days 1-5, and no copay for days 6-90, while for Inpatient Hospital Psychiatric, you will pay a $150 copay for days 1-5, and no copay for days 6-90. Additional Days for Inpatient Hospital-Acute are covered with no copay for days 91-100.

Outpatient Services See details

Outpatient hospital services are covered with a copay between $0 and $300, observation services have a copay between $140 and $300, and ambulatory surgical center services have a $50 copay. Individual and group sessions for outpatient substance abuse have a copay of $40, and outpatient blood services have no copay.

Partial Hospitalization See details

Partial Hospitalization is covered under the Wellcare Simple (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 by the Wellcare Simple (HMO) plan. Ground and air ambulance services have a $200 copay, and transportation services to a plan-approved health-related location have no copay and cover up to 48 one-way trips per year via rideshare, bus/subway, or medical transport.

Emergency Services See details

Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Wellcare Simple (HMO) plan. Emergency Services have a $140 copay, Urgently Needed Services have a $15 copay, and Worldwide Emergency Coverage has a $140 copay, all with no coinsurance. Worldwide Emergency Transportation is not covered.

Primary Care See details

Primary Care Physician Services are covered with no copay. Chiropractic Services are covered with a $10 copay for routine care. Occupational Therapy Services are covered with a $10 copay, while Physician Specialist Services, and Physical Therapy and Speech-Language Pathology Services each have a $10 copay.

Mental Health and Psychiatric services have a $40 copay for both individual and group sessions. Other Health Care Professional and Opioid Treatment Program Services have a $0-$10 copay. Additional Telehealth Benefits are covered with a $0-$40 copay.

Preventive Services See details

The Wellcare Simple (HMO) plan covers preventive services including an annual physical exam with no copay. Additional preventive services, including fitness benefits, alternative therapies, and remote access technologies, are covered with no copay. Kidney disease education services are covered with 20% coinsurance, and various other preventive services are covered with no copay.

Hearing Services See details

Wellcare Simple (HMO) offers hearing services including hearing exams with a $10 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with no copay, but inner ear, outer ear, and over the ear prescription hearing aids are not covered, and OTC hearing aids are not covered.

Vision Services See details

Vision services include eye exams and eyewear. Eye exams have a copay between $0 and $10, and routine eye exams have no copay; eyewear, including contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades, have no copay.

Dental Services See details

Dental services are covered, with a $10 copay for Medicare dental services. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), oral and maxillofacial surgery, and implant services all have a $0 copay. Maxillofacial prosthetics and orthodontics are not covered.

Home Infusion bundled Services See details

Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.

Dialysis Services See details

Dialysis Services are covered under the Wellcare Simple (HMO) plan, requiring a doctor's referral. There is a 20% coinsurance for these services.

Medical Equipment See details

Medical Equipment is covered under the Wellcare Simple (HMO) plan. Durable Medical Equipment (DME) has a 20% coinsurance and requires authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies are covered with a 20% coinsurance, and Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.

Diagnostic and Radiological Services See details

Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests with a copay between $0 and $30, and lab services with no copay. Radiological services include outpatient x-ray services with a $50 copay, diagnostic radiological services with a copay up to $150, and therapeutic radiological services with 20% coinsurance.

Home Health Services See details

Home Health Services are covered by the Wellcare Simple (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization and referral are required for this benefit.

Cardiac Rehabilitation Services See details

Cardiac Rehabilitation Services are covered with a doctor referral, however, 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 are not covered. There is a copay for this benefit; see the plan details for more information.

Skilled Nursing Facility (SNF) See details

Skilled Nursing Facility (SNF) services are covered under the Wellcare Simple (HMO) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20 and days 41-100, but there is a $214 copay for days 21-40.

Other Services See details

Other Services for the Wellcare Simple (HMO) plan includes Over-the-Counter (OTC) items with no copay, as well as a meal benefit with no copay and a doctor referral. Acupuncture, 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, 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.