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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 CA. This plan received an overall rating of 3 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 $1000.00 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 you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, you will pay no copay at a preferred pharmacy or via mail order. For standard generic drugs, you will pay 25% coinsurance. After your total drug costs reach $2000, you pay nothing for covered drugs.
Additional Benefits
The Wellcare Simple (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have copays, while outpatient services have copays that vary depending on the service. Emergency, urgent, and worldwide emergency services have a copay, and ambulance services also have a copay. Preventive, primary care, hearing, vision, and dental services are offered with no copays for many services, including eye exams, eyewear, and routine hearing exams. Home health, diagnostic, and skilled nursing facility services are covered, with some services requiring copays or coinsurance. The plan also covers other services, such as acupuncture and over-the-counter items with no copay, but some services, like worldwide emergency transportation and additional hours of care, are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered under the Wellcare Simple (HMO) plan. For Inpatient Hospital-Acute, you will pay a $50 copay for days 1-2, and no copay for days 3-90; for days 91-100, there is no copay. Inpatient Hospital Psychiatric has a $50 copay for days 1-2, and no copay for days 3-90. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered by the Wellcare Simple (HMO) plan. Outpatient hospital services have a copay between $0 and $75, observation services have a copay between $75 and $140, and Ambulatory Surgical Center (ASC) Services have no copay. Outpatient Substance Abuse Services have a $25 copay for both individual and group sessions, and Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple (HMO) plan, but requires prior authorization and a doctor's referral. You will have a $130 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 $150 copay, while Transportation Services to a plan-approved health-related location have no copay for up to 24 one-way trips per year, utilizing rideshare services, bus/subway, or medical transport; transportation services to any other health-related location are not covered.
Emergency Services See details
Emergency Services under the Wellcare Simple (HMO) plan include a $140 copay, with no coinsurance. Urgently Needed Services have no copay and no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage each have a $140 copay and no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple (HMO) plan offers primary care physician services, chiropractic services, occupational therapy, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Primary care physician services, chiropractic services, occupational therapy, physician specialist services, physical therapy and speech-language pathology services, and opioid treatment program services have no copay. Mental health and psychiatric individual and group sessions have a $25 copay. Additional telehealth benefits have a copay between $0 and $25.
Preventive Services See details
The Wellcare Simple (HMO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, including Fitness Benefit, In-Home Support Services, Alternative Therapies, and Remote Access Technologies, are covered with no copay. Kidney Disease Education Services are covered with a 20% coinsurance.
Hearing Services See details
Wellcare Simple (HMO) offers coverage for hearing exams with no copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered up to $500 per year, with no copay for all types. However, prescription hearing aids for the inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
The Wellcare Simple (HMO) plan covers vision services, including eye exams and eyewear. Eye exams and eyewear have no copay. Routine eye exams are limited to one per year. Eyewear has a combined maximum benefit of $300 per year.
Dental Services See details
Dental Services are covered with no copay for Medicare Dental Services, Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery; however, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered. For oral exams, you are limited to one visit every six months.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Wellcare Simple (HMO) plan, but prior authorization is required. 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) plan, with a doctor referral required. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and Prosthetic Devices with 20% coinsurance. The plan also covers Medical Supplies with 20% coinsurance, Diabetic Supplies with no copay, and Diabetic Therapeutic Shoes/Inserts with 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, lab services, all radiological services, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services. Diagnostic Procedures/Tests and Lab Services have no copay, while outpatient X-ray services have a $25 copay, and therapeutic radiological services have a 20% coinsurance.
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 with a doctor referral, but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, SET for PAD Services, and Additional Cardiac Rehabilitation Services are not covered. There is a copay for covered services, but the specific amount is not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Wellcare Simple (HMO) plan, with a doctor referral and prior authorization required. For days 1-20 and 31-100, there is no copay, but there is a $214 copay for days 21-30.
Other Services See details
The Wellcare Simple (HMO) plan covers acupuncture with no copay, though a doctor referral and prior authorization are required and is limited to 36 treatments per year. The plan also covers over-the-counter items with no copay up to $77 every three months, including nicotine replacement therapy and Naloxone. Other services like meal benefits, and several others are not covered.
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