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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 2026, 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 IL. This plan received an overall rating of 3 out of 5 stars in 2026.
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 $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 $3900.00 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 features an annual drug deductible of $615. For Tier 1 preferred generics, Tier 2 generics, and Tier 6 select care drugs, you will pay no copay when using a preferred pharmacy or preferred mail-order services. Standard pharmacies and standard mail-order options for these lower tier drugs require copays ranging from $5 to $30 depending on the supply duration. Higher tier prescription drugs are subject to coinsurance rather than flat copays. Tier 3 preferred brands and Tier 5 specialty drugs both require a 25% coinsurance, while Tier 4 non-preferred drugs require 32% coinsurance at preferred pharmacies and 33% coinsurance at standard pharmacies. These percentage-based costs apply across all available supply durations, helping you estimate your out-of-pocket expenses.
Additional Benefits
The Wellcare Simple Essential Value (HMO) plan offers robust coverage with no copay for primary care physician visits, annual physicals, and routine preventive services. For specialized medical care, members will pay a $25 copay for specialist visits and a $150 copay for emergency services, which is waived if hospitalized. Inpatient hospital stays require a daily copay of $325 for the first eight days of an acute stay, with no copay required for days 9 through 90. This plan also features strong supplemental benefits, including no copay for routine dental, vision, and hearing exams, alongside allowance coverage for hearing aids and eyewear. While many diagnostic and laboratory tests require no copay, durable medical equipment, home health services, and dialysis require a 20% coinsurance with no copay. Additionally, members can access over-the-counter items and chronic illness meal benefits with no copay and no coinsurance.
Inpatient Hospital See details
Wellcare Simple Essential Value (HMO) covers inpatient hospital services with no coinsurance, requiring a daily copay of $325 for days 1 to 8 of an acute stay and $275 for days 1 to 8 of a psychiatric stay, with no copay for days 9 through 90. Prior authorization is required, and additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Wellcare Simple Essential Value (HMO) covers outpatient services with no coinsurance, including outpatient hospital services with a copay of $0 to $280 and ambulatory surgical center visits for a $175 copay. Outpatient substance abuse sessions require a $40 copay with no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Wellcare Simple Essential Value (HMO) covers partial hospitalization services with a $175.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Wellcare Simple Essential Value (HMO) covers ground and air ambulance services with a $300 copayment and no coinsurance, subject to prior authorization. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Wellcare Simple Essential Value (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with no copay or coinsurance. Worldwide emergency and urgent care are partially covered up to a $50,000 maximum with a $150 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple Essential Value (HMO) offers primary care physician services with no copay and no coinsurance, and specialist visits for a $25 copay and no coinsurance. Outpatient therapy and mental health services require copays of $30 to $40 with no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by the Wellcare Simple Essential Value (HMO) plan, featuring no copay and no coinsurance for annual physicals, fitness benefits, alternative therapies, PERS, and screenings, though kidney disease education requires a 20% coinsurance with no copay. Sub-services that are not covered under this plan include health education, in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, home modifications, and counseling.
Hearing Services See details
Wellcare Simple Essential Value (HMO) covers hearing services with a $25 copay and no coinsurance for Medicare-covered exams, while routine exams and fitting evaluations have no copay or coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to $500 per ear annually, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Wellcare Simple Essential Value (HMO) partially covers vision services with no coinsurance and copays ranging from $0 to $25, though other eye exam services are not covered. Routine annual eye exams and eyewear have no copay, with a $200 annual maximum benefit for eyewear and prior authorization required for services.
Dental Services See details
Wellcare Simple Essential Value (HMO) partially covers dental services, offering Medicare-covered dental for a $25 copay and no coinsurance, and preventive and comprehensive services with no copay and no coinsurance. Comprehensive benefits are covered up to a $3,000 annual maximum, but maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Wellcare Simple Essential Value (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy and other drugs require 0% to 20% coinsurance with no copay, while Part B insulin is available for a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered under the Wellcare Simple Essential Value (HMO) with no copay and a 20% coinsurance. This coverage ensures you have access to necessary dialysis treatments with clear and predictable out-of-pocket costs.
Medical Equipment See details
Medical equipment is covered by Wellcare Simple Essential Value (HMO), with durable medical equipment, prosthetics, and medical supplies requiring no copay and 20% coinsurance. Diabetic supplies are covered with no copay, while diabetic therapeutic shoes and inserts carry a 20% coinsurance, with prior authorization required for these benefits.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Wellcare Simple Essential Value (HMO), with prior authorization required for all services. Diagnostic services feature no coinsurance, offering lab services with no copay and diagnostic tests with a copay of $0 to $100, while radiological services require a $50 copay for X-rays, a $0 minimum copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Wellcare Simple Essential Value (HMO) covers Home Health Services with no copay and a 20% coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Wellcare Simple Essential Value (HMO) covers Cardiac Rehabilitation Services with no coinsurance, but some services are covered while standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered. These excluded services carry copayments ranging from $30 to $65 depending on the specific therapy.
Skilled Nursing Facility (SNF) See details
Wellcare Simple Essential Value (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 to 20 and days 41 to 100, and a $218 daily copay for days 21 to 40. Prior authorization is required, no prior three-day hospital stay is needed, and additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
Wellcare Simple Essential Value (HMO) provides partial coverage for other services, offering over-the-counter (OTC) items and a chronic illness meal benefit with no copay and no coinsurance. Acupuncture and other additional services are not covered under this plan, and a referral is required for the meal benefit.
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