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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 Texas. 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 $3850.00 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 depending on the drug tier and the pharmacy you use. For preferred generic drugs, you pay no copay at a preferred pharmacy or preferred mail order, and a $10 copay at a standard pharmacy or standard mail order. The plan's coinsurance rates vary from 25% to 36% depending on the drug tier. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Wellcare Simple (HMO) plan offers a range of benefits, including inpatient and outpatient hospital services, with varying copays depending on the specific service. You'll have no copay for many services like primary care visits, preventive services, and routine hearing and vision exams. Other services, such as specialist visits, hearing exams, and dental services, have copays ranging from $20 to $280. This plan also includes coverage for ambulance and transportation services, emergency services, and home health services with no copay. Additionally, it provides benefits for hearing aids, eyewear, and dental services, with some limitations on coverage amounts and specific services.
Inpatient Hospital See details
Inpatient Hospital services are covered, including acute and psychiatric care. For acute care, you pay a $325 copay for days 1-6, and no copay for days 7-90, while psychiatric care has a $225 copay for days 1-6 and no copay for days 7-90.
Outpatient Services See details
Outpatient services, including outpatient hospital services, are covered by the Wellcare Simple (HMO) plan. Outpatient hospital services have a copay between $0 and $280, observation services have a copay between $140 and $280, and ambulatory surgical center services have a $200 copay. Outpatient substance abuse services have a $25 copay for individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with a $130 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance services are covered with a $250 copay for both ground and air ambulance services, and transportation services to plan-approved health-related locations are covered with no copay and up to 24 one-way trips per year, using rideshare, bus/subway, or medical transport. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Coverage and Urgent Coverage, are covered under the Wellcare Simple (HMO) plan. Emergency Services have a $140 copay, while Urgent Services have a $40 copay; both have no coinsurance. 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 $30 copay, and specialist services with a $25 copay. Mental health and psychiatric individual and group sessions have a $25 copay, physical therapy and speech-language pathology services have a $30 copay, and opioid treatment program services have a $25 copay. Additional telehealth benefits have a copay between $0 and $40. 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 include Fitness Benefit, Alternative Therapies, Remote Access Technologies, and Personal Emergency Response System (PERS), all with no copay. The plan also covers Kidney Disease Education Services with 20% coinsurance.
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. The plan provides up to $750 per year for prescription hearing aids, however, inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay between $0 and $25, and eyewear with no copay. Routine eye exams are covered with no copay, and you are allowed one per year. Eyewear has a combined maximum benefit of $200 per year for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $25 copay, 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 Prosthodontics, fixed with no copay. Orthodontic Services are covered up to a maximum of $2000 per year. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered under the Wellcare Simple (HMO) plan, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetic Devices, Medical Supplies, and Diabetic Equipment. Diabetic Supplies have no copay, and 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, with the Diagnostic Procedures/Tests having a copay between $0 and $50, Lab Services with no copay, and Diagnostic Radiological Services having a copay up to $280. Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a $75 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. While the plan states that Cardiac Rehabilitation Services benefits are covered, the specific services are not covered.
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 21-50, the copay is $214, and for days 51-100, there is no copay. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items and a Meal Benefit. 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. OTC items have no copay and a maximum benefit coverage amount of $78 every three months, and the plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit. Meal Benefits also have no copay and require a doctor's referral.
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