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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 2026, 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 3.5 out of 5 stars in 2026.
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 $615.00 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 $4500.00 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) Medicare plan features a $615.00 annual prescription drug deductible before your initial coverage begins. Under this plan, Tier 1 preferred generic drugs have no copay at preferred pharmacies, while Tier 5 specialty tier drugs also feature no copay at both preferred and standard pharmacies. Other tiers require coinsurance, including 25% for Tier 2 standard generics and Tier 4 non-preferred drugs, and 31% for Tier 3 preferred brand drugs. After your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. Furthermore, individuals who qualify for the low-income subsidy, or Extra Help, can reduce their Part D premium to $0.00. This plan provides a clear cost-sharing structure to help you estimate and manage your annual prescription medication expenses.
Additional Benefits
The Wellcare Simple (HMO) plan offers affordable access to essential medical care, featuring no copay and no coinsurance for primary care visits, specialist consultations, and routine preventive services. For inpatient hospital stays, members pay a $250 daily copay for the first four days and no copay for days five through 90, while outpatient hospital services range from no copay up to a $200 copay. Emergency care is covered with a $130 copay, and urgently needed services are available with no copay. Members also benefit from no copay and no coinsurance for routine dental care, annual vision exams, and general prescription hearing aids. Diagnostic lab tests, diabetic supplies, and home health services are also fully covered with no copay, while durable medical equipment and dialysis services require a 20% coinsurance. Note that some services, including eyewear, over-the-counter items, and routine transportation, are not covered under this plan.
Inpatient Hospital See details
Wellcare Simple (HMO) partially covers inpatient hospital benefits, which require a $250 daily copay for days 1 through 4, no copay for days 5 through 90, and no coinsurance. While up to 10 additional acute care days are covered at no copay, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Wellcare Simple (HMO) with no coinsurance and copays ranging from no copay for blood services up to $200 for outpatient hospital and observation services. Patients will also pay a $50 copay for ambulatory surgical center services and a $25 copay for outpatient substance abuse sessions.
Partial Hospitalization See details
Wellcare Simple (HMO) covers partial hospitalization benefits with a $140.00 copay and no coinsurance. Prior authorization and a doctor referral are required to receive these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Wellcare Simple (HMO), which offers ground and air ambulance services for a $150 copay and no coinsurance, while transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Wellcare Simple (HMO) covers emergency services with a $130 copay and no coinsurance, and urgently needed services with no copay and no coinsurance. Worldwide emergency services are partially covered up to a $50,000 maximum with a $130 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple (HMO) partially covers primary care services with no coinsurance, offering no copay for primary care visits, specialist consultations, and physical therapy, while mental health and psychiatric services require a $25 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services are partially covered by Wellcare Simple (HMO), offering no copay and no coinsurance for annual physical exams, fitness benefits, alternative therapies, remote access, and standard screenings, while kidney disease education requires a 20% coinsurance and no copay. Non-covered services include health education, in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, readmission prevention, wigs, weight management, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, smoking cessation, home safety devices, and counseling.
Hearing Services See details
Wellcare Simple (HMO) partially covers hearing services, providing routine hearing exams, fitting evaluations, and general prescription hearing aids with no copay and no coinsurance. Over-the-counter hearing aids, as well as inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered.
Vision Services See details
Vision Services under Wellcare Simple (HMO) are partially covered, offering one routine eye exam every year with no copay and no coinsurance. However, eyewear is not covered under this plan, which includes contact lenses, eyeglasses, lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by Wellcare Simple (HMO) with no copay and no coinsurance for covered preventive and comprehensive care. However, maxillofacial prosthetics, implant services, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
Wellcare Simple (HMO) covers home infusion bundled services, which require prior authorization and may involve step therapy. Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered by Wellcare Simple (HMO) with a 20% coinsurance and no copay, though a doctor referral is required.
Medical Equipment See details
Medical equipment benefits are covered by Wellcare Simple (HMO), with durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes requiring no copay and a 20% coinsurance. Diabetic supplies are covered with no copay and no coinsurance, and prior authorization is required for these services.
Diagnostic and Radiological Services See details
Wellcare Simple (HMO) covers diagnostic and radiological services with no copay or coinsurance for diagnostic tests, procedures, and lab services. Outpatient X-rays require a $25 copay, diagnostic radiological services carry a copay of up to $100, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home health services are covered by Wellcare Simple (HMO) with no copay and no coinsurance, although a doctor referral and prior authorization are required.
Cardiac Rehabilitation Services See details
Wellcare Simple (HMO) indicates that some Cardiac Rehabilitation Services are covered, but in practice, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Wellcare Simple (HMO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization and a doctor referral. There is no copay for days 1 through 20 and days 51 through 100, and a $218 daily copay for days 21 through 50, but additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Wellcare Simple (HMO) does not cover Other Services, meaning there is no coverage, copay, or coinsurance for acupuncture, over-the-counter (OTC) items, meal benefits, or highly integrated dual-eligible SNP services.
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