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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 2026 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 $6500.00 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 offers an Enhanced Alternative drug benefit with a prescription drug deductible of $615.00. After meeting this deductible, you pay cost-sharing during the initial coverage phase until total drug costs reach $2,100.00. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. For a 30-day supply, Tier 1 preferred generics have no copay at preferred pharmacies and a $10.00 copay at standard pharmacies, while Tier 5 specialty drugs have no copay at either. Tier 2 standard generics and Tier 4 non-preferred drugs require a 25% coinsurance at both preferred and standard pharmacies. Tier 3 preferred brands require a 36% coinsurance at preferred pharmacies and 37% coinsurance at standard pharmacies.
Additional Benefits
The Wellcare Simple (HMO) plan offers coverage designed to keep your out-of-pocket costs manageable, featuring no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits, urgent care, and outpatient therapy services require a low copay of up to $25 with no coinsurance. For inpatient hospital stays, members pay a $425 daily copay for the first 7 days, with no copay required for days 8 through 100. Routine dental, vision, and hearing services are highly accessible with no copay or coinsurance, including allowances for eyewear and hearing aids. Emergency services carry a $130 copay, while diagnostic tests and diabetic supplies are covered with no copay. However, some services like dialysis and durable medical equipment require a 20% coinsurance, and cardiac rehabilitation and over-the-counter items are not covered under this plan.
Inpatient Hospital See details
Wellcare Simple (HMO) partially covers inpatient hospital benefits with no coinsurance, though non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered. Acute stays require a $425 daily copay for days 1 to 7 (no copay for days 8 to 100), while psychiatric stays require a $325 daily copay for days 1 to 7 (no copay for days 8 to 90).
Outpatient Services See details
Wellcare Simple (HMO) covers outpatient hospital services with a 35% coinsurance and a $0 to $375 copay, and observation services with a 35% coinsurance and a $130 copay. Ambulatory surgical center services require a $300 copay with no coinsurance, outpatient substance abuse services have a $25 copay with no coinsurance, and blood services feature no copay and no coinsurance.
Partial Hospitalization See details
Wellcare Simple (HMO) covers partial hospitalization services with a $140.00 copay and no coinsurance. A doctor referral and prior authorization are required to receive this covered benefit.
Ambulance and Transportation Services See details
Wellcare Simple (HMO) partially covers ambulance and transportation services, providing ground and air ambulance coverage with a $250 copay and no coinsurance. Prior authorization is required for ambulance services, and 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 urgently needed services with a $25 copay, both with no coinsurance. Worldwide emergency and urgent care are partially covered up to a $50,000 maximum benefit with a $130 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple (HMO) covers primary care visits with no copay and no coinsurance, while specialist, therapy, telehealth, and mental health services require copays up to $25 and no coinsurance. Some chiropractic services are covered with a $5 copay and no coinsurance, but routine chiropractic and podiatry services are not covered.
Preventive Services See details
Wellcare Simple (HMO) provides partial coverage for preventive services, offering annual physical exams, fitness benefits, and screenings with no copay, while kidney disease education requires a 20% coinsurance. Several supplemental services are not covered, including health education, weight management programs, and in-home safety assessments.
Hearing Services See details
Wellcare Simple (HMO) covers routine hearing exams and fitting evaluations with no copay or coinsurance, while Medicare-covered exams require a $5 copay and no coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to a $500 annual maximum per ear, though OTC hearing aids and inner-ear, outer-ear, and over-the-ear prescription models are not covered.
Vision Services See details
Wellcare Simple (HMO) covers vision services with no deductible and no coinsurance, featuring eye exams for no copay to a $5 copay and eyewear with no copay. Covered benefits include one routine eye exam per year and a $100 annual maximum allowance for contacts, eyeglasses, lenses, frames, and upgrades.
Dental Services See details
Wellcare Simple (HMO) dental services are partially covered, excluding maxillofacial prosthetics, implant services, and orthodontics. Medicare-covered dental services require a $5 copay and no coinsurance, while all other covered dental services have no copay and no coinsurance.
Home Infusion bundled Services See details
Wellcare Simple (HMO) covers home infusion bundled services, requiring prior authorization for care. Covered Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs feature no copay and a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Wellcare Simple (HMO) covers dialysis services with 20% coinsurance and no copay, though a doctor referral is required.
Medical Equipment See details
Medical equipment is covered by Wellcare Simple (HMO), including durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes or inserts for a 20% coinsurance and no copay. Diabetic supplies are covered with no copay and no coinsurance, though prior authorization is required for these medical equipment benefits.
Diagnostic and Radiological Services See details
Wellcare Simple (HMO) covers diagnostic and radiological services, requiring prior authorization and doctor referrals for all services. Members pay no copay or coinsurance for diagnostic tests, procedures, and lab services, while outpatient X-rays require a $25 copay, diagnostic radiological services range from a $0 to $375 copay, and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
Home health services are covered under the Wellcare Simple (HMO) plan with no copay and no coinsurance. Prior authorization and a doctor referral are required to access these benefits.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Wellcare Simple (HMO) plan, meaning there is no coverage, copay, or coinsurance for these treatments. This lack of coverage applies to all associated sub-services, including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation.
Skilled Nursing Facility (SNF) See details
Wellcare Simple (HMO) partially covers Skilled Nursing Facility (SNF) services, requiring prior authorization and a doctor referral, but excluding additional days beyond Medicare-covered care. There is no coinsurance for this benefit, with no copay for days 1 to 20 and days 51 to 100, and a $218 daily copay for days 21 to 50.
Other Services See details
Other Services are not covered under the Wellcare Simple (HMO) plan. This means there is no coverage for acupuncture, over-the-counter (OTC) items, meal benefits, or dual eligible SNPs with highly integrated services.
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