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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 $420.00 deductible for prescription drugs. After meeting your deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy used. For preferred generic drugs, there is no copay at preferred pharmacies and preferred mail order, and a $10 copay at standard pharmacies and standard mail order. For specialty tier drugs, there is no copay regardless of the pharmacy used.
Additional Benefits
The Wellcare Simple (HMO) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays depending on the service. Emergency and primary care services, such as doctor visits, are covered with no copay. Additionally, this plan includes preventive, hearing, vision, and dental services, often with no copay or a set allowance. This plan also covers ambulance services with a copay, and offers transportation to health-related locations. Other benefits include partial hospitalization, home health services, and skilled nursing facilities with specific copay structures. The plan also offers additional benefits such as medical equipment, diagnostic and radiological services, dialysis services, and other services like acupuncture and over-the-counter items with specific cost-sharing arrangements.
Inpatient Hospital See details
Inpatient Hospital benefits with Wellcare Simple (HMO) include a $150 copay for days 1-2, and no copay for days 3-90 for Inpatient Hospital-Acute, with an additional 10 days covered with no copay for days 91-100. Inpatient Hospital Psychiatric has a $100 copay for days 1-2, and no copay for days 3-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional Days for Inpatient Hospital Psychiatric and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services have a copay between $0 and $125, while Observation Services have a copay of $125 to $140. Ambulatory Surgical Center Services and Outpatient Blood Services have no copay. Outpatient Substance Abuse individual and group sessions have a copay of $25.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple (HMO) plan, but requires prior authorization and a doctor referral. The copay for this benefit is $130.
Ambulance and Transportation Services See details
The Wellcare Simple (HMO) plan covers ambulance services with a $225 copay for both ground and air ambulance services. Transportation services to a plan-approved health-related location are covered with no copay, offering up to 24 one-way trips per year via rideshare, bus/subway, or medical transport, while transportation services to any other health-related location are not covered.
Emergency Services See details
Emergency services, including worldwide emergency coverage and urgently needed services, are covered by the Wellcare Simple (HMO) plan. Emergency services and worldwide emergency coverage have a $140 copay, while urgently needed services have no copay. Worldwide emergency transportation is not covered.
Primary Care See details
The Wellcare Simple (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, 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 services, physician specialist services, physical therapy and speech-language pathology services, and opioid treatment program services have no copay. Mental health specialty services, psychiatric services, and additional telehealth benefits have a copay between $0 and $25, depending on the service. Podiatry services and other health care professional services have a copay of $0.
Preventive Services See details
Wellcare Simple (HMO) covers preventive services, including an annual physical exam with no copay. The plan also covers additional preventive services such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit, all with no copay. Kidney disease education services are covered with 20% coinsurance.
Hearing Services See details
Wellcare Simple (HMO) covers hearing exams with no copay, as well as routine hearing exams and fitting/evaluation for hearing aids with no copay for one visit per year. Prescription hearing aids are covered up to $750 per year, but inner ear, outer ear, and over-the-ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams, eyewear, contact lenses, eyeglass lenses, eyeglass frames, and upgrades. Eye exams and eyewear have no copay, while eyewear has a combined maximum benefit of $200 per year.
Dental Services See details
Dental services include coverage for 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 with no copay. 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, 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 a 20% coinsurance and Prosthetic Devices with a 20% coinsurance. Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have a 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 by the Wellcare Simple (HMO) plan. Diagnostic Procedures/Tests and Lab Services have no copay, while Diagnostic Radiological Services have a copay of up to $50, and Therapeutic Radiological Services have 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 generally not covered by the Wellcare Simple (HMO) plan. This includes coverage for Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple (HMO) plan with prior authorization and a doctor referral required. You will have no copay for days 1-20, a $214 copay for days 21-30, and no copay for days 31-100.
Other Services See details
The Wellcare Simple (HMO) plan covers acupuncture with no copay, but requires prior authorization and a doctor's referral, and is limited to 36 treatments per year. Over-the-counter items are covered with no copay, and the plan provides a maximum benefit coverage amount of $49.00 every three months, including nicotine replacement therapy and Naloxone coverage. 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 are not covered.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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