Is WellCare Medicaid or Medicare?

Are you trying to understand, “is WellCare Medicaid or Medicare?” WellCare provides both Medicaid services and Medicare plans.

WellCare offers a range of health care plans under the Medicare Advantage program (also known as Part C) and coordinates with Medicaid through Dual Special Needs Plans (D-SNPs) for those eligible for both Medicare and Medicaid. In this article, we will explore how WellCare operates within these programs, what makes its plans distinctive, and how you can determine the right WellCare plan for your needs.


Key Takeaways

  • WellCare offers Medicare Advantage plans with additional benefits like drug, vision, hearing, and dental services, different from the Original Medicare, and caters to individuals over 65 or with specific disabilities.


  • Medicaid’s role through WellCare includes providing Dual Special Needs Plans (D-SNPs) for individuals who qualify for both Medicare and Medicaid, offering a comprehensive coverage including prescription drugs, dental, vision, and hearing benefits.


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Deciphering WellCare: Medicare Advantage or Medicaid?

WellCare has established a unique position in the healthcare sector with its diverse Medicare Advantage and Medicaid plans. To gain a better understanding of these offerings, we’ll begin by breaking them down. WellCare partners with Medicare to provide customers with Medicare Part A and Part B benefits through its Medicare Advantage plans.

These plans are more than just a reiteration of Original Medicare; they bring to the table valuable additional benefits.

Deciphering WellCare: Medicare Advantage or Medicaid?

However, WellCare’s involvement with Medicaid presents a different dynamic. Medicaid, a joint federal and state initiative, aims to assist individuals with limited income and resources in accessing healthcare services that aren’t typically covered by Medicare. WellCare integrates these Medicaid services into its offerings by providing Dual Special Needs Plans (D-SNPs) for individuals who qualify for both Medicare and Medicaid.

These plans offer a blend of benefits from both programs and provide additional Medicare coverage, including more services and reduced out-of-pocket costs compared to Original Medicare.


What is Medicare Advantage?

Medicare Advantage, also known as ‘Part C’ or an ‘MA Plan’, serves as an alternative to Original Medicare. It is a health plan provided by private companies such as WellCare under a contract with Medicare. It encompasses all Original Medicare services and often goes a step further to include additional coverage such as:


  • drug services
  • vision services
  • hearing services
  • dental services



Wellcare medicare Therefore, Medicare Advantage offers a more extensive coverage than Original Medicare. While Original Medicare offers Part A (Hospital Insurance) and Part B (Medical Insurance), Medicare Advantage plans go the extra mile to offer additional Medicare Advantage plan benefits, like prescription drug coverage and regular care for dental, vision, and hearing, which are not provided by Original Medicare.



These plans are generally available to those who are 65 years of age or older and are a U.S. citizen or a legal permanent resident for at least five consecutive years.


Understanding Medicaid’s Role with WellCare

Whereas Medicare Advantage plans are designed for individuals above 65 or those with certain disabilities, Medicaid extends support to those with limited income and resources. WellCare, as the Medicare brand for Centene Corporation, provides Dual Special Needs Plans (D-SNPs) that coordinate with Medicaid coverage.

The management of these plans is carried out through the D-SNP, which offers plan types such as HMO and PPO to cater to individual requirements and helps manage the entire cost of healthcare.

These Medicaid managed care plans offered by WellCare are accessible to individuals who meet the eligibility requirements for Medicaid and those who qualify for both Medicare and Medicaid. What sets WellCare’s Medicaid program apart from traditional Medicaid is that it provides additional benefits, including:


  • Prescription drug coverage
  • Dental benefits
  • Vision benefits
  • Hearing benefits


All of these benefits are provided within a comprehensive, risk-based managed care framework.


Dual Eligible Special Needs Plans (D-SNPs)


Wellcare medicare reviews One of the unique offerings within WellCare’s portfolio is the Dual Eligible Special Needs Plans (D-SNPs). These are a specialized category of Medicare Advantage plans intended for individuals who qualify for both Medicare and Medicaid assistance.

These plans are carefully crafted to address the unique requirements of dually eligible beneficiaries, providing them with a comprehensive coverage akin to Original Medicare along with customized benefits.

One of the key advantages of D-SNPs provided by WellCare is that they deliver supplementary support and advantages without additional charges.

This significantly aids in the reduction of out-of-pocket expenses for beneficiaries. To be eligible for a D-SNP under WellCare, individuals must meet the qualifications for both Medicare and Medicaid.

The Structure of WellCare Medicare Advantage Plans

Now that we’ve grasped the essence of WellCare’s Medicare Advantage and Medicaid plans, it’s time to further explore their structure. WellCare provides a variety of Medicare Advantage plans, such as HMO (Health Maintenance Organization) plans, PPO (Preferred Provider Organization) plans, and D-SNPs (Dual Eligible Special Needs Plans). Each plan type offers a unique blend of benefits, catering to different healthcare requirements.


WellCare includes prescription drug coverage in its Medicare Advantage plans, providing members with comprehensive healthcare benefits. This additional coverage helps members save on medication costs and ensures they have access to the medications they need. This ensures that beneficiaries have coverage not just for hospital and medical services, but also for their prescription medications.

Furthermore, WellCare provides a distinct Medicare Part D prescription drug plan for individuals requiring extensive prescription drug coverage.

Concluding the structure of WellCare’s plans are the supplementary benefits they provide. These include:


  • Vision, dental, and hearing coverage
  • Telehealth services
  • Wellness and fitness programs
  • In-home support services
  • Benefits for individuals with chronic illnesses


These benefits make WellCare’s plans a comprehensive choice for healthcare coverage.


Plan Types and Benefits

Within WellCare’s array of Medicare Advantage plans, you’ll find three main types: HMO, PPO, and Special Needs Plans. Each of these plan types caters to different healthcare needs and preferences.

WellCare’s Advantage HMO plans emphasize accessibility and affordability of care through an extensive network. On the other hand, PPO plans offer a wider coverage range compared to Original Medicare, making them a suitable choice for individuals who often need care outside of their local area. When comparing Medicare Advantage plans, it’s essential to consider these differences to make the best choice for your healthcare needs.

For individuals who qualify for both Medicare and Medicaid, WellCare offers D-SNPs, which offer targeted support and additional benefits at no extra cost. It’s worth noting that the copays and deductibles are subject to variation based on the selected WellCare plan type, impacting the overall expenses linked with each plan.


Prescription Drug Coverage in WellCare Plans

WellCare’s Medicare Advantage plans include the following features:


  • Prescription drug coverage
  • A formulary of covered drugs
  • Some options offering reduced premiums and $0 copays for Tier 1 prescriptions from a preferred cost share pharmacy
  • Members contributing 25% of the cost for formulary generic and brand-name drugs until they reach the annual out-of-pocket threshold of $7,400


Wellcare benefits



WellCare’s Medicare Advantage plans provide coverage for a diverse array of medications, encompassing both brand name and generic drugs as outlined in the plan’s formulary. However, it’s worth noting that WellCare plans may impose restrictions or limitations, such as quantity limits on certain drugs, which could affect your coverage.


Additional Benefits Exclusive to WellCare

Besides providing extensive medical and prescription drug coverage, WellCare Medicare Advantage plans offer an array of unique benefits, including a WellCare Medicare Advantage plan with:


  • Vision, dental, and hearing coverage
  • Telehealth services
  • Wellness and fitness programs
  • In-home support services
  • Benefits for individuals with chronic illnesses


These extra benefits provide added value and can significantly enhance your healthcare experience.

What sets WellCare apart is:


  • The broad network of providers it offers
  • Working in partnership with healthcare providers to develop top-notch, cost-efficient healthcare options
  • Providing interactive resources to aid in managing patient conditions, leading to improved healthcare outcomes.

Comparing Costs: WellCare Plans vs. Original Medicare

Cost is a primary factor for most individuals when selecting a healthcare plan. WellCare’s Medicare Advantage plans offer a cost advantage over Original Medicare in several areas. For instance, WellCare Medicare Advantage plans offer monthly premiums as low as $0 to approximately $60, which can be more affordable than the Part B premium usually paid by beneficiaries of Original Medicare.

In terms of copays, WellCare’s plans typically feature lower copays and limited out-of-pocket spending, in contrast to Original Medicare which does not have an out-of-pocket maximum. This makes WellCare’s plans a more cost-effective choice for many individuals.

When it comes to deductibles, WellCare Medicare Advantage plans offer the following benefits:


  • Minimal or non-existent deductibles, providing greater initial cost savings compared to deductibles under Original Medicare
  • Limited annual out-of-pocket expenses
  • A 25% contribution for covered generic and brand-name medications until the total out-of-pocket expenditure reaches $8,000 annually


These features ensure that out-of-pocket expenses are minimized for WellCare plan members.


Understanding Premiums and Copays

To assess the affordability of your health plan, it’s important to understand the associated premiums and copays. The determination of premiums and copays for WellCare’s Medicare Advantage plans is based on the Member’s Benefit Plan. Each plan type, such as HMO and PPO, has different premium and copay amounts, which are considered when assessing the overall cost of the plans.


Comparing Costs- WellCare Plans vs. Original Medicare



A copayment, also known as copay, is the payment required for a covered medical service. The copay costs for WellCare’s Medicare Advantage plans vary, with $0 for primary care, $25 for specialists, and $0 for Tier 1 prescription drugs. These copay amounts are often lower than those associated with Original Medicare, making WellCare’s plans a more affordable choice for many individuals.


Deductibles and Out-of-Pocket Expenses

Deductibles and out-of-pocket expenses are another important factor to consider. The deductible amounts in WellCare’s Medicare Advantage Plans can vary significantly, with options ranging from low to no deductible for enrollees.

WellCare’s plans often offer the advantage of lower or no deductibles when compared to Original Medicare. Additionally, unlike Original Medicare, which does not have a limit on out-of-pocket expenses, WellCare’s plans include a maximum out-of-pocket cap each plan year, providing extra financial security for enrollees.

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Enrollment Periods and Eligibility Criteria

Having explored WellCare’s offerings and their respective costs, we will now proceed to understand the enrollment periods and eligibility criteria for WellCare’s Medicare Advantage plans.

To enroll in WellCare’s plans, individuals must meet certain eligibility criteria:


  • They must meet the age requirement of 65 or older, or under 65 with a qualifying condition.
  • They need to reside within the plan’s service area.
  • They must possess Medicare Parts A and B.


When Enrollment Begins

Enrollment in WellCare’s Medicare Advantage plans begins during the Annual Election Period (AEP) or during a Special Enrollment Period (SEP) for those who qualify. The Annual Election Period (AEP) for WellCare’s Medicare Advantage occurs annually from October 15th to December 7th. During this period, beneficiaries have the opportunity to transition from one Medicare Advantage plan to another.


Wellcare medicare provider portal



Apart from the AEP, it is also possible to transition from Original Medicare to WellCare’s Medicare Advantage during the Medicare Advantage Open Enrollment Period (MA OEP), which takes place from January 1 to March 31.


Qualifying for WellCare Medicare Advantage

To qualify for WellCare’s Medicare Advantage, individuals must meet certain qualifications. These include:


  • Being at least 65 years old or under 65 with a qualifying condition
  • Residing within the plan’s service area
  • Possessing Medicare Parts A and B
  • Being either a U.S. citizen or lawfully present in the U.S.


WellCare’s Medicare Advantage plans are offered in multiple geographical regions. To be eligible, you need to be located within a service area that provides plan types such as HMO, PPO, and Special Needs Plans.

It’s important to note, however, that while it is possible to have Medicare while residing abroad, Medicare usually does not provide coverage for care received outside the United States. As such, permanent residence outside the U.S. can impact your coverage.


Accessing Personal Support for Enrollment

Personal support can greatly facilitate the process of enrolling in a health plan. WellCare provides personal support for enrollment through their Broker Support Call Center and Broker Self-Service Portal. They offer assistance with PPO Plans, HMO Plans, D-SNP Plans, and C-SNP Plans. It’s recommended to present your WellCare Member ID card during enrollment.

Personal support for WellCare plan enrollment is accessible from Monday to Friday, 8 a.m. to 8 p.m. Additional support is also available on weekends for Fidelis Care Medicaid Members in New Jersey. You can reach out to WellCare’s support by contacting the Broker Support Call Center or by calling specific hotlines during their operating hours.

How to Choose the Right Plan for Your Needs

Selecting the right WellCare plan requires:


  • Assessment of your healthcare needs
  • Verification of your preferred healthcare providers’ availability within the WellCare network
  • Analysis of your prescription drug needs


The right plan for you depends on your personal healthcare needs and preferences, how often you need healthcare services, and how much you can afford to pay for these services.


Evaluating Health Care Service Needs

In assessing your healthcare needs, take into account factors like your frequency of doctor visits, any chronic conditions you may have, and the type of health care services you regularly require. For example, if you have a chronic condition that requires regular checkups, you might need a plan with lower copays for office visits.

On the other hand, if you seldom need healthcare services, you might prefer a plan with a lower monthly premium.


Checking Provider Network Availability

Also, before opting for a WellCare plan, ensure that your preferred healthcare providers are included in the WellCare network. You can check this using the WellCare Find a Provider tool on their official website.


Wellcare medicare customer service



If your preferred provider is not within the network, you may want to consider whether you’re willing to change providers or whether you’d prefer to find a plan that includes your preferred provider.


Analyzing Prescription Drug Requirements

Lastly, contemplate your prescription drug needs. If you regularly take prescription medications, it would be beneficial to select a plan that covers your medications. You can check whether your specific medications are covered by a WellCare plan by referring to the formularies available on the WellCare website or by using their drug search tool.

There are different types of Medicare Advantage plans.

These are the most common plans offered by several different insurance companies.

  • Health Maintenance Organization Plans (HMO)
  • Preferred Provider Organization Plans (PPO)
  • Private Fee-for-Service Plans (PFFS)
  • Special Needs Plans (SNPs)


We can help you find the right plan to fit your needs, so if this already seems overwhelming don’t worry!


Navigating the world of healthcare insurance can be daunting, but with the right information, you can make an informed decision that suits your healthcare needs and budget. WellCare’s Medicare Advantage and Medicaid plans offer comprehensive coverage options, from HMO and PPO plans to Dual Eligible Special Needs Plans.

With added benefits such as prescription drug coverage, dental, vision, and hearing services, and access to a vast provider network, WellCare’s plans offer a significant advantage over Original Medicare.

However, it’s crucial to understand that the best plan for you depends on your individual healthcare needs and preferences. Therefore, take the time to evaluate your healthcare needs, check provider network availability, and analyze your prescription drug requirements before deciding. With this guide, you’re now well-equipped to navigate WellCare’s offerings and choose the plan that best fits your needs.

Frequently Asked Questions



What is another name for WellCare?

WellCare is also known as Centene, which has been consolidating its Medicare options under the Wellcare brand, combining with previous brands such as Allwell, Health Net, Fidelis Care, Trillium Advantage, ‘Ohana Health Plan, and TexanPlus. This transition began on January 1, 2022.


→  What’s the difference between Humana and WellCare?

The main difference between Humana and WellCare is that Humana offers Medicare Supplement Insurance plans in addition to Medicare Part D and Medicare Advantage plans, while WellCare only offers Part D and Medicare Advantage plans in certain areas. This gives Humana a wider range of coverage options for Medicare beneficiaries.


→  Is WellCare of Kentucky Medicaid or Medicare?

WellCare of Kentucky primarily provides government-sponsored managed care services through Medicaid, serving families, children, and individuals with complex medical needs across the state.


→  What is the WellCare controversy?

The WellCare controversy involves allegations of overcharging Medicare by about $46 million and false claims submitted to Medicare and Medicaid programs, including falsely inflating the amount spent on medical care to avoid returning money to Medicaid and other programs in various states.


→  What are the eligibility requirements for enrolling in WellCare Medicare Advantage?

To enroll in WellCare Medicare Advantage, you must be 65 or older, or under 65 with a qualifying condition, reside within the plan’s service area, and have Medicare Parts A and B. Meeting these eligibility requirements is essential.

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Russell Noga
( Medicare Expert )

Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.