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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 $4500.00 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 is met, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy used. For Tier 1 preferred generic drugs, there is no copay at preferred pharmacies and preferred mail order, and a $10 copay at standard pharmacies and standard mail order. For specialty tier drugs, there is no copay at any pharmacy.
Additional Benefits
The Wellcare Simple (HMO) plan offers a variety of benefits, including inpatient and outpatient hospital services, with varying copays. You'll find no copays for primary care physician visits, preventive services like annual physical exams, routine hearing exams, and eyewear. The plan also covers services like ambulance, emergency, and some dental services, but some services require coinsurance or have copays. Additional benefits include coverage for hearing aids up to $350 per year, and a meal benefit with no copay. The plan provides coverage for home health services, and skilled nursing facility stays, but some services, like cardiac rehabilitation and some dental services, are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, but require prior authorization. For Inpatient Hospital-Acute, you'll pay a copay of $370 for days 1-8, and no copay for days 9-90; for Inpatient Hospital Psychiatric, you'll pay a copay of $285 for days 1-8, and no copay for days 9-90. Additional Days for Inpatient Hospital-Acute, Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered by the Wellcare Simple (HMO) plan, including outpatient hospital services with a copay between $0 and $450, observation services with a copay between $125 and $450, and ambulatory surgical center services with a $250 copay. Outpatient substance abuse services are covered with a $25 copay for individual and group sessions, and outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple (HMO) plan, but requires prior authorization. The copay for this benefit is $105.
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 $300 copay, and there is no coinsurance. 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 by the Wellcare Simple (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, and Urgently Needed Services have a $40 copay; there is no coinsurance for any of these services. 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, and Occupational Therapy Services with a $35 copay. The plan also covers Physician Specialist Services with a $25 copay, Mental Health Specialty Services with a $25 copay, and Physical Therapy and Speech-Language Pathology Services with a $35 copay. Additionally, the plan covers Additional Telehealth Benefits with a copay between $0-$40, and Opioid Treatment Program Services with a $25 copay. 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. Additional preventive services are covered, and other services such as health education, in-home safety assessments, personal emergency response systems, and others are not covered. Kidney disease education services have a 20% coinsurance, and other preventive services have no copay.
Hearing Services See details
Wellcare Simple (HMO) covers hearing exams with a $25 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a maximum benefit of $350 per year, but inner ear, outer ear, and over-the-ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$25, and eyewear with no copay. Eyewear includes contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, all with no copay. There is a combined maximum benefit of $100 for eyewear per year.
Dental Services See details
The Wellcare Simple (HMO) plan covers Medicare Dental Services with a $25 copay, and other dental services with no copay for oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, and oral and maxillofacial surgery. Orthodontic services are covered up to a maximum of $1000 per year, but prosthodontics, 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, the copay is $35.00; 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 by the Wellcare Simple (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a 20% coinsurance with no copay, while Prosthetic Devices and Medical Supplies have a 20% coinsurance and no copay. Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a copay between $0 and $100, and Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $400, and Therapeutic Radiological Services have a 20% coinsurance. Outpatient X-Ray Services have a $100 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 Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Wellcare Simple (HMO) plan, but require prior authorization. For days 1-20, and days 51-100, there is no copay, and for days 21-50, the copay is $214.
Other Services See details
Other Services under the Wellcare Simple (HMO) plan includes a meal benefit with no copay, but a doctor referral is required. Acupuncture, Over-the-Counter (OTC) Items, 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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