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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 TX. This plan received an overall rating of 3.5 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 $3450.00 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. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay at preferred pharmacies and a $10 copay at standard pharmacies. The plan offers an initial coverage phase where you pay a copay or coinsurance until your total drug costs reach $2000. Once you reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Wellcare Simple (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have copays, while outpatient services often have copays, including those for substance abuse and mental health services. The plan covers ambulance and transportation services, and emergency services with copays. Preventive, vision, and dental services often have no copay, and hearing services include hearing exams and prescription hearing aids. The plan also covers home health services, and offers additional benefits like over-the-counter items and meal benefits with no copay. Certain services like cardiac rehabilitation and additional hours of care are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered. For acute care, you pay a $350 copay for days 1-6, and no copay for days 7-90; for psychiatric care, you pay a $325 copay for days 1-6, and no copay for days 7-90.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay of $0-$300, Observation Services with a copay of $140-$300, Ambulatory Surgical Center (ASC) Services with a $150 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
Partial Hospitalization is covered under the Wellcare Simple (HMO) plan, but requires prior authorization. You will have a copay of $130.00 for this service.
Ambulance and Transportation Services See details
The Wellcare Simple (HMO) plan covers ambulance services with a $250 copay for both ground and air ambulance services, and it covers transportation services with no copay, including services not usually covered by Medicare plans. Transportation services to any health-related location are limited to 24 one-way trips per year, and uses rideshare services, bus/subway, and medical transport. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Wellcare Simple (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay, and Urgently Needed Services have a $35 copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $20 copay, physician specialist services with a $20 copay, and mental health specialty services with a $25 copay for individual and group sessions. The plan also covers other health care professional services with a copay between $0 and $20, psychiatric services with a $25 copay for individual and group sessions, physical therapy and speech-language pathology services with a $20 copay, additional telehealth benefits with a copay between $0 and $35, and opioid treatment program services with a $20 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Wellcare Simple (HMO) plan covers preventive services, including an annual physical exam with no copay, and additional preventive services with a copay. Personal Emergency Response System (PERS), Alternative Therapies, and Fitness Benefit also have no copay. Kidney Disease Education Services have 20% coinsurance. Other preventive services, including Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, have no copay.
Hearing Services See details
Wellcare Simple (HMO) offers hearing services that include hearing exams with a $20 copay. Routine hearing exams and fitting/evaluation for hearing aids have no copay and are each limited to one visit per year. Prescription hearing aids are covered up to $750 per year, and all types of prescription hearing aids have no copay, with a limit of two visits per year, but hearing aids for the inner, outer, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services are covered, including eye exams and eyewear. Eye exams have a copay between $0 and $20, while routine eye exams have no copay. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades, also have no copay, with a combined maximum benefit of $300 per year.
Dental Services See details
Dental services are covered, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery with no copay. Orthodontic services are covered up to a maximum of $3,000 per year, and maxillofacial prosthetics, implant services, and orthodontics are not covered.
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, and 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, with a coinsurance of 20%.
Medical Equipment See details
The Wellcare Simple (HMO) plan covers Durable Medical Equipment (DME) with 20% coinsurance and requires prior authorization, but does not cover DME for use outside the home. Prosthetic devices and medical supplies are covered with 20% coinsurance, and diabetic supplies are covered with no copay, while diabetic therapeutic shoes/inserts have 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Wellcare Simple (HMO) plan. Diagnostic Procedures/Tests have a copay between $0 and $50, while Lab Services have no copay. Diagnostic Radiological Services have a copay up to $300, Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a $50 copay.
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 not covered by the Wellcare Simple (HMO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple (HMO) plan, but require prior authorization. For days 1-20, there is no copay, for days 21-40 there is a $214 copay, and for days 41-100, there is no copay. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items and meal benefits with no copay. Acupuncture, 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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