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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 2025 to people living in Select counties in TX. 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 $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 features an annual prescription drug deductible of $615. Beneficiaries can enjoy no copay for tier 1 preferred generics, tier 2 generics, and tier 6 select care drugs when utilizing preferred pharmacies or preferred mail order services. For standard pharmacies and standard mail order, copays for these lower-tier drugs range from $5 to $30 depending on the tier and supply duration. For higher-tier medications, costs are structured as coinsurance rather than flat copays. Tier 3 preferred brands and tier 5 specialty drugs require a 25% coinsurance, while tier 4 non-preferred drugs carry a 35% coinsurance. These coinsurance rates remain consistent across both preferred and standard pharmacy networks.
Additional Benefits
The Wellcare Simple (HMO) plan offers affordable healthcare coverage with no copays or coinsurance for primary care physician visits, home health care, and annual preventive physicals. For inpatient hospital stays, members pay a daily copay for the first six days and no copay for subsequent days, with no coinsurance required. Outpatient services, specialist visits, and diagnostic procedures generally feature low, predictable copays and no coinsurance, helping to keep your out-of-pocket costs manageable. Members also benefit from comprehensive dental, vision, and hearing coverage, featuring no copays or coinsurance for routine exams, preventive dental care up to a $2,000 annual limit, and eyewear up to a $300 maximum. Additionally, the plan covers over-the-counter items and up to 12 one-way transportation trips per year to approved locations with no copay or coinsurance. Durable medical equipment, diabetic supplies, and dialysis services are also covered, typically requiring either no copay or a 20% coinsurance.
Inpatient Hospital See details
Wellcare Simple (HMO) offers coverage for inpatient hospital services with no coinsurance, requiring prior authorization for both acute and psychiatric stays. For acute care, there is a $450 daily copay for days 1-6 and no copay for days 7-95, while psychiatric care costs a $325 daily copay for days 1-6 and no copay for days 7-90; hospital upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Wellcare Simple (HMO) covers outpatient services with no coinsurance, featuring copays of $0 to $300 for outpatient hospital services, $150 to $300 per stay for observation services, and $150 for ambulatory surgical center services. Outpatient substance abuse sessions require a $25 copay with no coinsurance, while outpatient blood services have no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Wellcare Simple (HMO) covers partial hospitalization services with a $175.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Wellcare Simple (HMO) covers Medicare-approved ground and air ambulance services with a $250 copay and no coinsurance. Transportation services are partially covered, offering up to 12 one-way trips per year to plan-approved locations with no copay and no coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Wellcare Simple (HMO) emergency services are covered with a $150 copay and no coinsurance, and urgently needed services are covered with a $35 copay and no coinsurance, with both copays waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent services are partially covered up to a $50,000 maximum with a $150 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple (HMO) provides primary care physician services with no copay and no coinsurance, while specialist, occupational, physical, and speech therapy visits require a $20 copay and no coinsurance. Mental health and psychiatric sessions have a $25 copay and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services under Wellcare Simple (HMO) are partially covered, offering no copay and no coinsurance for annual physicals, memory fitness, alternative therapies, and select screenings, while kidney disease education has no copay but a 20% coinsurance. Sub-services that are not covered include health education, in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, smoking cessation, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Wellcare Simple (HMO) covers hearing services with a $20 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fitting evaluations. Prescription hearing aids are partially covered with no copay or coinsurance up to $500 per ear annually, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Wellcare Simple (HMO) offers partially covered vision services, which include one annual routine eye exam with no copay and no coinsurance, while other eye exam services are not covered. Covered eyewear, including contacts and eyeglasses, has no copay, no coinsurance, and no deductible up to a $300 annual maximum.
Dental Services See details
Wellcare Simple (HMO) offers partially covered dental services with no copay and no coinsurance for preventive and most comprehensive care up to a $2,000 yearly maximum, while Medicare-covered dental services require a $20 copay and no coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered, and prior authorization is required for most services.
Home Infusion bundled Services See details
Wellcare Simple (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this plan, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require no copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Wellcare Simple (HMO) covers medical equipment, including durable medical equipment, prosthetics, and medical supplies, with no copay and a 20% coinsurance. Diabetic supplies are covered with no copay, while diabetic therapeutic shoes or inserts require a 20% coinsurance, with prior authorization needed for these services.
Diagnostic and Radiological Services See details
Wellcare Simple (HMO) covers diagnostic services with no coinsurance, offering lab services at no copay and diagnostic procedures with a $0 to $50 copay. Covered radiological services require prior authorization, featuring diagnostic radiology starting at no copay with no coinsurance, outpatient X-rays at a $50 copay with coinsurance, and therapeutic radiology with a copay and a minimum 20% coinsurance.
Home Health Services See details
Wellcare Simple (HMO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Wellcare Simple (HMO) covers cardiac rehabilitation services with no coinsurance, although copays apply to specific treatments. Standard cardiac rehabilitation has a $50 copay, intensive cardiac rehabilitation has a $65 copay, pulmonary rehabilitation has a $40 copay, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) has a $30 copay.
Skilled Nursing Facility (SNF) See details
Wellcare Simple (HMO) covers skilled nursing facility services with no coinsurance, requiring prior authorization and allowing admission without a prior three-day hospital stay. There is no copay for days 1 to 20 and days 41 to 100, but a $218 copay applies for days 21 to 40, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Wellcare Simple (HMO) partially covers other services, offering over-the-counter (OTC) items and chronic illness meal benefits with no copay and no coinsurance, though acupuncture is not covered. A referral is required to access the meal benefit.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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