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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 Statewide 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 meeting the deductible, your costs will vary depending on the drug tier and the pharmacy you use. For example, you will pay no copay for preferred generic drugs at preferred pharmacies, but will pay a 25% coinsurance for standard generic drugs. The plan offers an "Enhanced Alternative" drug benefit. After your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs.
Additional Benefits
The Wellcare Simple (HMO) plan offers comprehensive coverage with a variety of benefits. This plan includes coverage for inpatient and outpatient hospital services, with varying copays depending on the service. It also provides coverage for primary care, preventive services, and mental health services, often with no copay. Additional benefits include hearing, vision, and dental services, with no copays for routine exams and some eyewear. The plan also covers ambulance and transportation services, emergency services, and diagnostic services. Other covered services include home health, skilled nursing facility, and home infusion, with some services requiring copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with prior authorization required. For Inpatient Hospital-Acute, you pay a $350 copay for days 1-7, and no copay for days 8-90; for Inpatient Hospital Psychiatric, you pay a $325 copay for days 1-7, and no copay for days 8-90.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $350, observation services with a copay between $125 and $350, ambulatory surgical center services with a $275 copay, and outpatient substance abuse services with a $30 copay for individual and group sessions. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple (HMO) plan, but requires prior authorization. You will have a $105 copay for this benefit.
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 $290 copay, while transportation services to a plan-approved health-related location have no copay for up to 12 one-way trips per year using rideshare services, bus/subway, or medical transport.
Emergency Services See details
Emergency Services under the Wellcare Simple (HMO) plan has a $125 copay, with no coinsurance, and the copay is waived if admitted to the hospital within 24 hours. Urgently Needed Services have a $40 copay with no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage each have a $125 copay with no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care benefits include coverage for primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $25 copay, physician specialist services with a $25 copay, mental health specialty services with a $30 copay for individual or group sessions, other health care professional services with a copay between $0 and $25, psychiatric services with a $30 copay for individual or group sessions, physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits with a copay between $0 and $40, and opioid treatment program services with a $25 copay. Podiatry services are not covered.
Preventive Services See details
The Wellcare Simple (HMO) plan covers preventive services, including an annual physical exam with no copay. Other preventive services, like glaucoma screening and diabetes self-management training, are covered with no copay, while kidney disease education services have a 20% coinsurance.
Hearing Services See details
Wellcare Simple (HMO) covers hearing exams with a $25 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. The plan also covers prescription hearing aids with a maximum benefit of $500 per year, but does not cover prescription hearing aids for the inner ear, outer ear, or over the ear.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay of $0-$25, and routine eye exams have no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, have no copay, with a combined maximum plan benefit of $400 per year.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $25 copay, and Other Dental Services with coverage for 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, each with no copay. Orthodontic Services are covered up to a maximum of $5,000 per year. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered, with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Wellcare Simple (HMO) plan. You will pay 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, while Durable Medical Equipment for use outside the home is not covered. Prosthetics and Medical Supplies are covered with a 20% coinsurance for Medicare-covered services, and Diabetic Equipment is covered with a coinsurance and copay for some services.
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 of at most $350, Therapeutic Radiological Services with coinsurance of at most 20%, 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 covered by the Wellcare Simple (HMO) plan, but the plan does not cover any of the sub-services. The plan has a copay for the Cardiac Rehabilitation Services, but the copay information is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple (HMO) plan with prior authorization required, with no copay for days 1-20 and 61-100, and a $214 copay for days 21-60. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Under the Wellcare Simple (HMO) plan, acupuncture is covered with no copay, and over-the-counter items are covered with no copay. The plan does not cover 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.
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