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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 $4150.00 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 the deductible, you will pay the following costs depending on the drug tier. For example, you will pay no copay for preferred generic drugs at a preferred pharmacy, or a $10 copay at a standard pharmacy. For other tiers, you may pay coinsurance, such as 25% for standard generic drugs. Once your total drug costs reach $2000, you will enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs.
Additional Benefits
The Wellcare Simple (HMO) plan offers a range of benefits with varying costs. This plan includes no copay for primary care visits, preventive services, and many dental and vision services. The plan covers inpatient hospital stays with a copay, and also offers coverage for outpatient services, ambulance services, and emergency services with copays and coinsurance. Additional benefits include coverage for hearing aids, home health services, and durable medical equipment with no copay or a copay, as well as some coinsurance. Other services like skilled nursing facility stays, and dialysis services are also covered with a copay or coinsurance. The plan also covers over-the-counter items with no copay, and acupuncture with no copay.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered with a copay of $375 for days 1-6 and no copay for days 7-90 for Acute, and a copay of $325 for days 1-6 and no copay for days 7-90 for Psychiatric. Additional days for Inpatient Hospital-Acute are covered with no copay for days 91-100, but Non-Medicare-covered stays and Upgrades are not covered.
Outpatient Services See details
Outpatient Services include outpatient hospital services with a 35% coinsurance and a copay between $0 and $275, observation services with a 35% coinsurance and a $140 copay, ambulatory surgical center services with a $300 copay, outpatient substance abuse services with a $25 copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Wellcare Simple (HMO) covers partial hospitalization with a $130 copay, and requires prior authorization and a doctor referral.
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 $250 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Coverage and Worldwide Urgent Coverage, are covered by the Wellcare Simple (HMO) plan with a $140 copay, while Urgently Needed Services have a $25 copay; there is no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
Wellcare Simple (HMO) covers primary care physician services with no copay, chiropractic services with a $5 copay, occupational therapy services with a $5 copay, physician specialist services with a $5 copay, mental health specialty services with a $25 copay for individual and group sessions, podiatry services with a $5 copay, other health care professional services with a copay between $0 and $5, psychiatric services with a $25 copay for individual and group sessions, physical therapy and speech-language pathology services with a $5 copay, additional telehealth benefits with a copay between $0 and $25, and opioid treatment program services with a $5 copay. Routine chiropractic care is 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 include Fitness Benefit, Alternative Therapies, and Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), all with no copay. Kidney Disease Education Services has a 20% coinsurance. Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are also covered with no copay.
Hearing Services See details
The Wellcare Simple (HMO) plan covers hearing exams with a $5 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay; prescription hearing aids are covered with a maximum plan benefit of $500 per year, but the plan does not cover OTC hearing aids or prescription hearing aids for the inner, outer, or over the ear.
Vision Services See details
The Wellcare Simple (HMO) plan covers vision services including eye exams and eyewear. Eye exams have a copay of $0-$5, and routine eye exams have no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, are covered with no copay, and have a combined maximum benefit of $100 per year.
Dental Services See details
The Wellcare Simple (HMO) plan covers Medicare Dental Services with a $5 copay, and covers 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, but does not cover Maxillofacial Prosthetics, Implant Services, and Orthodontics. Oral Exams are limited to one visit every six months, Dental X-Rays are limited to one every 12-36 months, and Other Diagnostic Dental Services are limited to one per lifetime.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is 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, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple (HMO) plan, but a doctor referral is required. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Wellcare Simple (HMO) plan, including Durable Medical Equipment (DME), Prosthetics, Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Prosthetic Devices also have a 20% coinsurance. Medical Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Diabetic Supplies have no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with no copay, lab services with no copay, and outpatient X-ray services with a $25 copay. Therapeutic Radiological Services have a coinsurance of at most 20%, and Diagnostic Radiological Services have a copay of at most $275.
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 the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is a copay, but the specific amount is not listed.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple (HMO) plan, with a doctor referral and prior authorization required. For days 1-20 and 41-100, there is no copay, but days 21-40 have a $214 copay; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services under the Wellcare Simple (HMO) plan includes acupuncture with no copay and over-the-counter items with no copay, up to $33 every three months. Meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and other services are not covered.
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