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Wellcare Simple (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Simple (HMO) in 2025, please refer to our full plan details page.
Wellcare Simple (HMO) is a HMO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select Counties in PA. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Wellcare 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 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 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 $5900.00 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) 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 you use. For the initial coverage phase, you may pay no copay for preferred generic drugs at preferred pharmacies, and 25% coinsurance for standard generic drugs. You will pay no copay for specialty drugs. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Wellcare Simple (HMO) plan offers coverage for a range of healthcare services with varying cost-sharing. Inpatient hospital stays have a $300 copay for days 1-7, with no copay for subsequent days, while outpatient services have copays that vary by service. The plan includes no copays for primary care visits, preventive services, and many vision and dental services, but members should be aware of cost-sharing for other services, such as ambulance, emergency, and specialist visits.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a copay of $300 for days 1-7, and no copay for days 8-90. Additional days for inpatient hospital-acute have no copay, while non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, and outpatient substance abuse services, are covered by the Wellcare Simple (HMO) plan. Outpatient hospital services have a copay between $0 and $350, observation services have a copay between $125 and $350, and ambulatory surgical center services have a copay of $275. Outpatient substance abuse individual and group sessions have a copay of $25. Outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Wellcare Simple (HMO) plan and requires prior authorization. The copay for this benefit is $105.
Ambulance and Transportation Services See details
Ambulance and Transportation Services include coverage for ground and air ambulance services with a $250 copay, and transportation services to a plan-approved health-related location with no copay for up to 12 one-way trips per year. Transportation to any other health-related location is not covered.
Emergency Services See details
Emergency Services are covered by the Wellcare Simple (HMO) plan with a $125 copay and no coinsurance, and urgently needed services have a $40 copay with no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay with no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple (HMO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $15 copay, physician specialist services with a $15 copay, mental health specialty services with a $25 copay for individual and group sessions, podiatry services with a $15 copay, other health care professional services with a $0-$15 copay, psychiatric services with a $25 copay for individual and group sessions, physical therapy and speech-language pathology services with a $15 copay, additional telehealth benefits with a $0-$40 copay, and opioid treatment program services with a $15 copay. Routine chiropractic care is not covered.
Preventive Services See details
The Wellcare Simple (HMO) plan covers preventive services, including an annual physical exam with no copay. Additionally, the plan covers alternative therapies, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit, all with no copay.
Hearing Services See details
Wellcare Simple (HMO) covers hearing exams with a $15 copay, and routine hearing exams and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a maximum benefit of $500 per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and neither are OTC hearing aids.
Vision Services See details
Vision services include eye exams with a copay of $0-$15, and eyewear, with a $0 copay for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. There is a combined maximum plan benefit coverage of $400 for all eyewear every year.
Dental Services See details
The Wellcare Simple (HMO) plan covers Medicare Dental Services with a $15 copay, and other dental services like oral exams, dental x-rays, and cleanings with no copay. Orthodontic services are covered up to a $5,000 maximum. Some services, such as maxillofacial prosthetics, implant services, 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. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and prior authorization required, Prosthetic Devices with 20% coinsurance, Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with no copay, Lab Services with no copay, Diagnostic Radiological Services with a copay up to $350, Therapeutic Radiological Services with 20% coinsurance, and Outpatient X-Ray Services with a $50 copay. Prior authorization is required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the Wellcare 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 Simple (HMO) plan.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple (HMO) plan. For days 1-20 and 61-100, there is no copay, but for days 21-60, the copay is $214. Additional days beyond Medicare coverage and non-Medicare-covered stays are not covered.
Other Services See details
Other Services with the Wellcare Simple (HMO) plan includes coverage for Over-the-Counter (OTC) Items with no copay and a maximum benefit of $118 every three months, but Acupuncture, Meal Benefit, 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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