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Wellcare Simple Essential Value (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple Essential Value (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 Value (HMO) in 2025, please refer to our full plan details page.
Wellcare Simple Essential Value (HMO) is a HMO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select Counties in Illinois. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Wellcare Simple Essential Value (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 Value (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 Value (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 Value (HMO) plan has a $420 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For drugs in the preferred generic tier, you will pay no copay at preferred and mail order pharmacies, or a $10 copay at standard pharmacies. For other tiers, you will pay coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for your Part D drugs.
Additional Benefits
The Wellcare Simple Essential Value (HMO) plan offers a range of benefits, including inpatient and outpatient services, with varying copays. You'll find no copay for primary care visits, preventive services like annual physical exams, and some vision and dental services. Hearing exams have a $25 copay, and the plan covers prescription hearing aids. Additional benefits include coverage for ambulance services with a $300 copay, emergency services with a $140 copay, and home health services with a 20% coinsurance. The plan also covers services like durable medical equipment, diagnostic and radiological services, and skilled nursing facility stays, each with specific cost-sharing details. The plan also offers a $45 maximum plan benefit coverage amount for over-the-counter items every three months.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both requiring prior authorization. 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 are not covered, nor are upgrades for Inpatient Hospital-Acute.
Outpatient Services See details
Outpatient services are covered by this plan, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $280, observation services have a copay between $140 and $280, ambulatory surgical center services have a $175 copay, and outpatient substance abuse services have a copay of $40 for both individual and group sessions. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Wellcare Simple Essential Value (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 by the Wellcare Simple Essential Value (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, including Worldwide Emergency Coverage and Worldwide Urgent Coverage, have a $140 copay and no coinsurance. Urgently Needed Services have no copay and no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple Essential Value (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy with a $30 copay, and specialist services with a $25 copay. Mental health individual and group sessions have a $40 copay, while physical therapy and speech-language pathology services have a $30 copay. The plan also covers additional telehealth benefits with a 20% coinsurance and a copay ranging from $0 to $40, and opioid treatment program services with a $25 copay. Podiatry services are not covered.
Preventive Services See details
The Wellcare Simple Essential Value (HMO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services are covered, and the plan offers no copay for Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit.
Hearing Services See details
The Wellcare Simple Essential Value (HMO) plan covers hearing exams with a $25 copay, and covers routine hearing exams and fitting/evaluation for hearing aids with no copay. This plan also covers prescription hearing aids, but does not cover OTC hearing aids, and only covers prescription hearing aids (all types), but not inner, outer, or over the ear prescription hearing aids.
Vision Services See details
The Wellcare Simple Essential Value (HMO) plan covers vision services, including eye exams with a copay of $0-$25, and eyewear with no copay. Eyewear includes contact lenses, eyeglass lenses and frames, and upgrades, all with no copay.
Dental Services See details
The Wellcare Simple Essential Value (HMO) plan covers dental services, including 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. The plan has a $25 copay for Medicare dental services, and 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, prosthodontics (removable and fixed), and oral and maxillofacial surgery. 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, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. For Medicare Part B Insulin Drugs, there is a $35 copay; 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 under the Wellcare Simple Essential Value (HMO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, and Medical Supplies have a 20% coinsurance. Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
The Wellcare Simple Essential Value (HMO) plan covers Diagnostic and Radiological Services, including all diagnostic services and radiological services. Diagnostic Procedures/Tests have a copay between $0 and $100, while Lab Services have no copay. Diagnostic Radiological Services have a copay up to $280, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have a $55 copay.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple Essential Value (HMO) plan with a 20% coinsurance, and no copay. 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 Value (HMO) plan, but the plan does not cover the services. The copay for these services is not mentioned.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20 and 41-100, there is no copay, but there is a $214 copay for days 21-40. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Under Other Services, 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. Over-the-Counter (OTC) Items and Meal Benefits are covered with no copay, and a $45 maximum plan benefit coverage amount for OTC items every three months.
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