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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 $37.00. 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 features an Enhanced Alternative prescription drug benefit with an annual deductible of $615. After meeting this deductible, you will pay no copay for Tier 1 preferred generics at preferred pharmacies, while standard pharmacies charge a $10 copay. Other tiers require a coinsurance ranging from 25% to 37%, though Tier 5 specialty drugs feature no copay at both preferred and standard pharmacies. Once your yearly out-of-pocket drug costs reach $2,100, you will enter the catastrophic coverage phase and pay nothing for covered Part D drugs. Additionally, beneficiaries who qualify for the low-income subsidy can reduce their Part D costs to zero. This plan provides structured and predictable prescription drug costs to help you manage your healthcare budget.
Additional Benefits
The Wellcare Simple (HMO) plan offers affordable healthcare coverage with no copay and no coinsurance for primary care visits, annual physicals, and home health services. For more intensive care, inpatient hospital stays require a daily copay of $425 for the first seven days, while emergency room visits carry a $130 copay and urgent care costs $25, both with no coinsurance. Outpatient hospital services generally involve a 35% coinsurance and copays ranging from no copay up to $375. Specialist visits, physical therapy, and covered dental services require a low $5 copay and no coinsurance, while routine vision and hearing exams are available with no copay. The plan also covers prescription hearing aids up to $500 per ear and eyewear up to a $100 annual limit with no copay. However, some services like routine transportation, cardiac rehabilitation, acupuncture, 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, requiring a $425 daily copay for days 1-7 of acute stays (no copay for days 8-100) and a $325 daily copay for days 1-7 of psychiatric stays (no copay for days 8-90). Non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Wellcare Simple (HMO) covers outpatient hospital services with a 35% coinsurance and a copay ranging from no copay to $375, alongside observation services at a 35% coinsurance and a $130 copay. Ambulatory surgical center services require a $300 copay and outpatient substance abuse sessions require a $25 copay, both with no coinsurance. Outpatient blood services are covered with no copay, no deductible, and no coinsurance.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Wellcare Simple (HMO) with a $140.00 copay and no coinsurance. Prior authorization and a doctor referral are required to receive this care.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Wellcare Simple (HMO), with ground and air ambulance services requiring a $250.00 copay and no coinsurance. Transportation services to plan-approved and any health-related locations are not covered under this plan.
Emergency Services See details
Emergency services are covered by Wellcare Simple (HMO) with a $130 copay and no coinsurance, while urgent care has a $25 copay and no coinsurance. Worldwide emergency and urgent care are partially covered up to a $50,000 limit with a $130 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits are partially covered by Wellcare Simple (HMO), offering primary care physician services with no copay and no coinsurance, though podiatry and routine chiropractic services are not covered. Other covered services, including specialist visits, physical therapy, and occupational therapy, require a $5 copay, while mental health and psychiatric services have a $25 copay, all with no coinsurance.
Preventive Services See details
Wellcare Simple (HMO) partially covers preventive services with no copay and no coinsurance for annual physicals, glaucoma screenings, and fitness benefits, while kidney disease education requires a 20% coinsurance and no copay. Multiple supplemental services, including health education, weight management, in-home safety assessments, and counseling, are not covered.
Hearing Services See details
Wellcare Simple (HMO) partially covers hearing services, offering routine exams and fitting evaluations annually with no copay and no coinsurance. Covered hearing exams have a $5 copay and no coinsurance, and prescription hearing aids (all types) are covered up to $500 per ear each year with no copay and no coinsurance. Over-the-counter (OTC) hearing aids, as well as inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered.
Vision Services See details
Wellcare Simple (HMO) covers vision services with no deductible or coinsurance, including one routine eye exam per year and eyewear with no copay. Other eye exams have a copay of up to $5, and eyewear has a combined annual benefit limit of $100.
Dental Services See details
Wellcare Simple (HMO) offers partially covered dental services, though maxillofacial prosthetics, implant services, and orthodontics are not covered. Covered Medicare dental services require a $5 copay and no coinsurance, while all other covered dental services feature no copay and no coinsurance.
Home Infusion bundled Services See details
Wellcare Simple (HMO) covers home infusion bundled services with prior authorization, including Medicare Part B insulin drugs for a $35 copay and no coinsurance. Other covered Part B chemotherapy, radiation, and miscellaneous drugs require no copay and carry a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple (HMO) plan with a doctor referral, featuring no copay and a 20% coinsurance.
Medical Equipment See details
Wellcare Simple (HMO) covers medical equipment, including durable medical equipment (DME), prosthetics, and diabetic therapeutic shoes, with a 20% coinsurance and no copay. Diabetic supplies are covered with no copay and no coinsurance, though prior authorization is required for most equipment and services.
Diagnostic and Radiological Services See details
Wellcare Simple (HMO) covers diagnostic and radiological services, requiring prior authorization and referrals for all services. Diagnostic tests, procedures, and lab services have no copay and no coinsurance, while outpatient X-rays require a $25 copay and diagnostic radiological services have a copay of $0 to $375, both with no coinsurance. Therapeutic radiological services require a 20% coinsurance and no copay.
Home Health Services See details
Home Health Services are covered by Wellcare Simple (HMO) with no copay and no coinsurance. Prior authorization and a doctor referral are required to receive these services.
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 cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services.
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 to 20 and days 51 to 100, a $218 daily copay for days 21 to 50, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are not covered under the Wellcare Simple (HMO) plan. There is no coverage, copay, or coinsurance provided for acupuncture, over-the-counter (OTC) items, meal benefits, or highly integrated services for dual eligible SNPs.
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