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Wellcare Simple (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Simple (HMO-POS) in 2025, please refer to our full plan details page.
Wellcare Simple (HMO-POS) is a HMO-POS plan offered by Centene Corporation available for enrollment in 2025 to people living in Select counties in NY. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Wellcare Simple (HMO-POS) 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-POS).
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-POS), 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 $8300.00 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-POS) plan has a $420 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will have no copay at preferred pharmacies and mail order, and a $10 copay at standard pharmacies. For standard generic drugs, you will pay 25% coinsurance. Preferred brand drugs have a 36% coinsurance, and non-preferred drugs have a 28% coinsurance. Specialty tier drugs have no copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase.
Additional Benefits
The Wellcare Simple (HMO-POS) plan offers a wide range of benefits with varying costs. The plan covers inpatient hospital stays with a copay that varies by days, and outpatient services with copays and coinsurance. Additionally, the plan includes coverage for ambulance services, emergency services, primary care, preventive services, hearing, vision, dental, home infusion, dialysis, and medical equipment. This plan also provides coverage for diagnostic and radiological services, home health services, and skilled nursing facilities. The plan offers additional services like acupuncture and meal benefits, while also covering mental health, and substance abuse services. Copays and coinsurance amounts vary depending on the specific service.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with prior authorization required. For Inpatient Hospital-Acute, you pay a $445 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you pay a $400 copay for days 1-5, and no copay for days 6-90. Additional days and non-Medicare covered stays for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
The Wellcare Simple (HMO-POS) plan covers outpatient services including outpatient hospital services with a 30% coinsurance and a copay between $0 and $500, observation services with a 30% coinsurance and a $110 copay, ambulatory surgical center services with a $475 copay, and outpatient substance abuse services with a $35 copay for both individual and group sessions. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple (HMO-POS) plan, but requires prior authorization. You will pay an $80 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Wellcare Simple (HMO-POS) plan. Ground and air ambulance services each have a $350 copay, with no coinsurance, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage have a $110 copay, while Worldwide Urgent Coverage has a $25 copay; all have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple (HMO-POS) plan covers primary care physician services with no copay, and chiropractic services with a $15 copay. Occupational therapy services have a $35 copay, while specialist visits have a $25 copay. Individual and group mental health and psychiatric sessions have a $35 copay, while physical therapy and speech-language pathology services have a $35 copay. Additional telehealth benefits have a copay between $0 and $35, and Opioid Treatment Program Services have a $25 copay.
Preventive Services See details
The Wellcare Simple (HMO-POS) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, like glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit, are covered with no copay. The plan also covers kidney disease education services with 20% coinsurance.
Hearing Services See details
Wellcare Simple (HMO-POS) covers hearing exams with a $25 copay, and routine hearing exams and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a maximum plan benefit of $750 per year, while inner ear, outer ear, and over the ear prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
The Wellcare Simple (HMO-POS) plan covers vision services, including eye exams with a copay of $0-$25, and eyewear with no copay. The plan offers routine eye exams once per year with no copay, and covers contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades with no copay. There is a combined maximum benefit of $200 per year for all eyewear.
Dental Services See details
The Wellcare Simple (HMO-POS) plan covers dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services with no copay. Medicare dental services have a $25 copay. Orthodontic services are covered, but restorative services, endodontics, periodontics, prosthodontics, maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Wellcare Simple (HMO-POS) plan. 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 are covered by the Wellcare Simple (HMO-POS) plan, including Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/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 all diagnostic services, diagnostic procedures/tests with a copay between $0 and $35, and lab services with no copay. Radiological services are also covered, including diagnostic radiological services with a copay up to $500, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with a $50 copay.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple (HMO-POS) plan with no copay and no coinsurance, though additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover 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. There is a copay for these services, but the exact amount 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 21-70 the copay is $214, and for days 71-100 there is no copay. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Wellcare Simple (HMO-POS) plan covers acupuncture with no copay, but requires prior authorization and is limited to 12 treatments per year. Meal benefits are also covered with no copay and a doctor referral. Other services such as over-the-counter items, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and others are not covered.
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