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Wellcare 'Ohana Simple (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare 'Ohana Simple (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare 'Ohana Simple (HMO) in 2025, please refer to our full plan details page.
Wellcare 'Ohana Simple (HMO) is a HMO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select counties in HI. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Wellcare 'Ohana Simple (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 'Ohana Simple (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 'Ohana Simple (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 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 $9350.00 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 'Ohana Simple (HMO) plan has a $420 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will have no copay at a preferred pharmacy or preferred mail order, and a $10 copay at a standard pharmacy or standard mail order. Specialty tier drugs have no copay. The plan also has coinsurance for other tiers, ranging from 25% to 41%.
Additional Benefits
The Wellcare 'Ohana Simple (HMO) plan offers a range of benefits with varying costs. Hospital stays have a copay, while outpatient services involve copays and coinsurance. The plan also covers ambulance services, emergency care, and a variety of primary care services with copays. Preventive services like annual exams are covered with no copay, while hearing and vision services have copays. Dental benefits include coverage for various services, and home infusion, dialysis, and medical equipment are covered with coinsurance or copays. Skilled nursing facility stays have a specific copay structure, and other services like acupuncture are covered.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for acute care, with a $450 copay for days 1-4, and no copay for days 5-90. Additional days for inpatient hospital-acute have no copay for days 91-120, with 30 additional days per benefit period. Inpatient Hospital Psychiatric benefits are covered, with a $500 copay for days 1-4, and no copay for days 5-90, but additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a 35% coinsurance and a copay between $0 and $450, Observation Services with a 35% coinsurance and a $110 copay, Ambulatory Surgical Center (ASC) Services with a $400 copay, Outpatient Substance Abuse Services with a $25 copay for both individual and group sessions, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare 'Ohana Simple (HMO) plan, but requires prior authorization. The copay for this benefit is $80.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Wellcare 'Ohana Simple (HMO) plan. Medicare-covered Ground and Air Ambulance Services have a $350 copay, with no coinsurance. Transportation Services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Wellcare 'Ohana Simple (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, while Urgently Needed Services have a $45 copay; all three services have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare 'Ohana Simple (HMO) plan covers primary care physician services with no copay and 35% coinsurance, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, physician specialist services with a copay between $25-$55, mental health specialty services with a $25 copay, other health care professional services with a copay between $0-$55, psychiatric services with a $25 copay, physical therapy and speech-language pathology services with a $25 copay, and additional telehealth benefits with a copay between $0-$55 and 35% coinsurance. Opioid treatment program services are covered with a copay between $25 and $55. Podiatry services are not covered.
Preventive Services See details
Preventive services include no copay for an annual physical exam, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit; however, some services such as health education, in-home safety assessments, and others are not covered. Kidney Disease Education Services have a 20% coinsurance.
Hearing Services See details
Hearing exams are covered with a $25 copay, while routine hearing exams and fitting/evaluation for hearing aids have 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. OTC hearing aids are not covered.
Vision Services See details
The Wellcare 'Ohana Simple (HMO) plan covers vision services, including eye exams and eyewear. Eye exams have a copay between $0 and $55, while routine eye exams have no copay. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades, are covered with no copay, up to a combined maximum of $100 per year.
Dental Services See details
The Wellcare 'Ohana Simple (HMO) plan covers Medicare Dental Services with a copay of $25-$55, and other dental services including 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. Orthodontic services have a maximum plan benefit of $1500 per year, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Part B insulin drugs with a $35 copay, and Medicare Part B chemotherapy/radiation drugs and other Medicare Part B drugs with a coinsurance between 0% and 20%. Prior authorization is required for all services.
Dialysis Services See details
Dialysis Services are covered under the Wellcare 'Ohana Simple (HMO) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered by the Wellcare 'Ohana Simple (HMO) plan, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies and Diabetic Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance with no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a copay between $0 and $55, lab services with no copay, diagnostic radiological services with a copay up to $450, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with a $50 copay. All services require prior authorization.
Home Health Services See details
Home Health Services are covered by the Wellcare 'Ohana Simple (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 not covered by the Wellcare 'Ohana Simple (HMO) plan. The plan does not provide coverage for Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare 'Ohana Simple (HMO) plan. There is no copay for days 1-20 and 71-100, but there is a $214 copay for days 21-70.
Other Services See details
Other Services includes acupuncture with no copay, but requires prior authorization and is limited to 24 treatments per year; however, over-the-counter items, meal benefits, 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.
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