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Wellcare Simple Essential (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple Essential (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Simple Essential (HMO) in 2025, please refer to our full plan details page.
Wellcare Simple Essential (HMO) is a HMO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select counties in IL. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Wellcare Simple Essential (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 Essential (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 Essential (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 $2900.00 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 Essential (HMO) plan has an enhanced alternative drug benefit. The plan has a $420 deductible. In the initial coverage phase, after the deductible, you will pay a $0 copay for preferred generic drugs at preferred and mail-order pharmacies, and a $10 copay at standard pharmacies. Standard generic drugs have a 25% coinsurance, while preferred brand drugs have a 42-43% coinsurance. Non-preferred drugs have a 28% coinsurance, and specialty tier drugs have no copay. 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 Essential (HMO) plan offers a variety of benefits with varying costs. You'll find coverage for inpatient hospital stays, outpatient services, and emergency care with copays ranging from $0 to $325. Additionally, the plan includes benefits like hearing, vision, and dental services, often with no copay or low copays. The plan also covers services like ambulance, home health, and medical equipment, with costs determined by copays or coinsurance, such as 20% for some services. Other benefits include preventive services with no copay, and a meal benefit. However, some services such as routine chiropractic and podiatry, and additional hours of care are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $325 copay for days 1-8 and no copay for days 9-90; for Inpatient Hospital Psychiatric, you pay a $275 copay for days 1-8 and no copay for days 9-90. Additional days and non-Medicare covered stays for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $280, Observation Services with a copay between $140 and $280, Ambulatory Surgical Center (ASC) Services with a $175 copay, Individual and Group Sessions for Outpatient Substance Abuse with a copay of $40, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple Essential (HMO) plan, but requires prior authorization. The copay for this benefit is $130.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered. Ground and air ambulance services have a $300 copay, with 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 under the Wellcare Simple Essential (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay with no coinsurance, while Urgently Needed Services has no copay and no coinsurance; however, Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple Essential (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 physical therapy and speech-language pathology services with a $20 copay. Mental health and psychiatric services have a $40 copay for individual and group sessions. Other health care professional services have a copay between $0 and $20. Additional telehealth benefits have a 20% coinsurance and a copay between $0 and $40. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include an annual physical exam with no copay, and additional services such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit with no copay. Kidney Disease Education Services have a 20% coinsurance.
Hearing Services See details
The Wellcare Simple Essential (HMO) plan covers hearing exams with a $20 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered up to $1000 per year, but prescription hearing aids for the inner and outer ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include 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, have no copay, with a combined maximum benefit of $300 per year.
Dental Services See details
The Wellcare Simple Essential (HMO) plan covers Medicare Dental Services with a $20 copay. Other dental services include 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. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while the coinsurance for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple Essential (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance for Medicare-covered items, and Diabetic Equipment. Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
The Wellcare Simple Essential (HMO) plan covers Diagnostic and Radiological Services. Diagnostic Procedures/Tests have a copay between $0 and $100, and Lab Services have no copay. Diagnostic Radiological Services have a copay up to $280, Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $50 copay.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple Essential (HMO) plan, with a 20% coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Wellcare Simple Essential (HMO) plan, but all sub-services are not covered. This means that you will not have to pay a copay or coinsurance for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple Essential (HMO) plan. You will have no copay for days 1-20 and 41-100, but a $214 copay for days 21-40. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) items with no copay, and a meal benefit with no copay, but 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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