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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 2026, 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 2026.
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 $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 $4200.00 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 features an annual prescription drug deductible of $615. For cost savings, this plan offers no copay for Tier 1 (Preferred Generic) and Tier 2 (Generic) medications when filled at a preferred pharmacy or through preferred mail order. Additionally, Tier 6 (Select Care Drugs) are available with no copay across all pharmacies and mail order options. Higher-tier medications require coinsurance rather than flat copays, such as a 25% coinsurance for Tier 3 (Preferred Brand) and Tier 5 (Specialty Tier) drugs. Tier 4 (Non-Preferred Drugs) carry a 34% coinsurance at preferred pharmacies and mail order, or 35% coinsurance at standard pharmacies. Utilizing preferred network pharmacies and mail-order services helps maximize your savings under this Medicare plan.
Additional Benefits
The Wellcare Simple Essential (HMO) plan offers robust everyday health coverage with no copay for primary care visits, routine physical exams, and urgent care. Specialist visits require a $20 copay, while dental, vision, and hearing benefits feature no copays for routine services, including up to $3,000 annually for preventive and comprehensive dental care. Additionally, the plan covers prescription hearing aids up to $500 per ear and eyewear up to a $100 annual limit with no copay. For emergency and hospital needs, emergency room visits carry a $150 copay, while inpatient hospital stays require a $375 daily copay for the first eight days and no copay thereafter. Outpatient services feature copays ranging from $0 to $400, and standard home health care, dialysis, and durable medical equipment are covered with a 20% coinsurance and no copay. The plan also includes no-copay benefits for over-the-counter items and diagnostic lab services to help manage your healthcare costs.
Inpatient Hospital See details
Inpatient hospital services are covered by Wellcare Simple Essential (HMO) with no coinsurance, requiring a $375 daily copay for days 1 through 8 of acute stays and a $290 daily copay for days 1 through 8 of psychiatric stays, with no copay for days 9 through 90. Additional days and non-Medicare-covered stays are not covered, and prior authorization is required.
Outpatient Services See details
Wellcare Simple Essential (HMO) covers outpatient services with no coinsurance, featuring copays ranging from $0 to $400 for outpatient hospital services and $150 to $400 for observation services. Ambulatory surgical center services require a $300 copay, outpatient substance abuse sessions have a $40 copay, and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered under the Wellcare Simple Essential (HMO) plan with a $175.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Wellcare Simple Essential (HMO) covers Medicare-approved ground and air ambulance services with a $350 copay and no coinsurance, though prior authorization is required. Transportation services to plan-approved or health-related locations are not covered under this plan.
Emergency Services See details
Wellcare Simple Essential (HMO) covers emergency services with a $150 copay (waived if admitted within 24 hours) and urgently needed services with no copay, both featuring no coinsurance. Worldwide emergency and urgent services are partially covered up to a $50,000 maximum with a $150 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple Essential (HMO) offers primary care visits with no copay and no coinsurance, specialist visits for a $20 copay and no coinsurance, and telehealth services with a $0 to $40 copay and 20% coinsurance. Therapy and psychiatric services require a $40 copay and no coinsurance, chiropractic services are partially covered with routine chiropractic care not covered, and podiatry services are not covered.
Preventive Services See details
Wellcare Simple Essential (HMO) partially covers preventive services, offering annual physical exams, fitness benefits, alternative therapies, and select screenings with no copay and no coinsurance. Kidney disease education is also covered with no copay but requires a 20% coinsurance, while several sub-services like health education, nutritional benefits, and in-home support are not covered.
Hearing Services See details
Wellcare Simple Essential (HMO) covers Medicare-covered hearing exams for a $20 copay and no coinsurance, as well as routine exams and fitting evaluations with no copay or coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to $500 per ear annually, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Wellcare Simple Essential (HMO) with no coinsurance, offering covered eye exams with a $0 to $20 copay and eyewear with no copay up to a $100 annual maximum. While routine annual eye exams are covered with no copay, other eye exam services are not covered, and prior authorization is required.
Dental Services See details
Wellcare Simple Essential (HMO) offers partially covered dental services, featuring a $20 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for preventive and comprehensive services up to a $3,000 yearly limit. Prior authorization is required for most treatments, and maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Wellcare Simple Essential (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Medicare Part B insulin drugs under this plan have a $35 copay and no coinsurance, while chemotherapy and other Part B drugs require a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Wellcare Simple Essential (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Wellcare Simple Essential (HMO) covers 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 and inserts require a 20% coinsurance, with prior authorization required for these services.
Diagnostic and Radiological Services See details
Wellcare Simple Essential (HMO) covers diagnostic and radiological services, with prior authorization required for all services. Diagnostic lab services carry no copay or coinsurance, diagnostic tests range from a $0 to $100 copay with no coinsurance, and radiological services vary from a $0 starting copay for diagnostic scans to a $50 copay for X-rays and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the Wellcare Simple Essential (HMO) plan with no copay and a 20% coinsurance. Prior authorization is required to receive these benefits.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Wellcare Simple Essential (HMO) plan, as all associated sub-services, including intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD), are excluded from coverage.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Wellcare Simple Essential (HMO) with no coinsurance, featuring no copay for days 1 to 20 and 41 to 100, and a $218 copay for days 21 to 40. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Wellcare Simple Essential (HMO) partially covers Other Services, providing over-the-counter (OTC) items and a chronic illness meal benefit with no copay and no coinsurance. Acupuncture is not covered under this plan, and a referral is required to access the meal benefit.
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