Wellcare Simple (HMO-POS)

Inpatient Hospital See details

The Wellcare Simple (HMO-POS) plan covers inpatient hospital stays with a copay of $275 for days 1-8, and no copay for days 9-90. Additional days for inpatient hospital-acute, non-Medicare-covered stays for inpatient hospital-acute, upgrades for inpatient hospital-acute, additional days for inpatient hospital psychiatric, and non-Medicare-covered stays for inpatient hospital psychiatric are not covered.

Outpatient Services See details

Outpatient services include outpatient hospital services with a copay between $0 and $280, observation services with a copay between $140 and $280, and ambulatory surgical center services with a $175 copay. Outpatient substance abuse services, including individual and group sessions, have a copay of $40. Outpatient blood services are covered with no copay.

Partial Hospitalization See details

Partial Hospitalization is covered by the Wellcare Simple (HMO-POS) plan, but requires prior authorization. The copay for this benefit is $130.

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 copay of $225, while transportation services to a plan-approved health-related location have no copay, with a limit of 24 one-way trips per year.

Emergency Services See details

Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage each have a $140 copay, while Worldwide Urgent Coverage has a $140 copay. Worldwide Emergency Transportation is not covered. There is a maximum plan benefit coverage amount of $50,000 for Worldwide Emergency Services.

Primary Care See details

The Wellcare Simple (HMO-POS) plan covers primary care physician services with no copay. Chiropractic services have a $10 copay, while occupational therapy services have a $10 copay and no coinsurance.

Specialist visits and physical therapy have a $10 copay. Mental health services have a $40 copay for individual and group sessions, and psychiatric services have a $40 copay for individual and group sessions.

Additional telehealth benefits have a 20% coinsurance and a copay between $0 and $40, and opioid treatment program services have a $10 copay.

Preventive Services See details

Preventive services include a $0 copay for an annual physical exam and no copay for Medicare-covered preventive services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Kidney Disease Education Services have 20% coinsurance, while Additional Preventive Services, and Other Preventive Services may have copays. Other services such as Health Education, In-Home Safety Assessment, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.

Hearing Services See details

Hearing exams are covered with a $10 copay, routine hearing exams have no copay, and fitting/evaluation for hearing aids have no copay, with each service being limited to one visit per year. Prescription hearing aids are covered with a maximum plan benefit of $1,500 per year, with a limit of two visits per year, and no copay, but inner ear, outer ear, and over the ear prescription hearing aids, and OTC hearing aids are not covered.

Vision Services See details

Vision services include eye exams and eyewear, with prior authorization required for both. Eye exams have a copay of $0-$10, and routine eye exams have no copay. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades, has no copay, and a combined maximum plan benefit of $500 per year.

Dental Services See details

Dental services include Medicare Dental Services with a $10 copay, 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), and Oral and Maxillofacial Surgery, all with no copay. Orthodontic Services are covered up to a maximum of $5000. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.

Home Infusion bundled Services See details

Home Infusion bundled Services are covered, and require prior authorization. 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 20% coinsurance for these services.

Medical Equipment See details

Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Prosthetic Devices have a 20% coinsurance, and Medical Supplies have a 20% coinsurance. For Diabetic Supplies, there is no copay, while for Diabetic Therapeutic Shoes/Inserts there is a 20% coinsurance.

Diagnostic and Radiological Services See details

Diagnostic and Radiological Services, including Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services, are covered. Diagnostic Procedures/Tests have a maximum copay of $50, and Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $280, Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $25 copay.

Home Health Services See details

Home Health Services are covered by the Wellcare Simple (HMO-POS) plan, with a 20% 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 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. The copay for these services is not specified.

Skilled Nursing Facility (SNF) See details

Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple (HMO-POS) plan, but require prior authorization. For days 1-20, there is no copay, for days 21-40 the copay is $214, and for days 41-100, there is no copay. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.

Other Services See details

The Wellcare Simple (HMO-POS) plan's other services include Over-the-Counter (OTC) items and Meal Benefit, both with no copay, and acupuncture, Dual Eligible SNPs with Highly Integrated Services, 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, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, 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. The OTC items have a maximum plan benefit coverage amount of $207.00 every three months.