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Gundersen MN Quartz Med Advantage Value (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Gundersen MN Quartz Med Advantage Value (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Gundersen MN Quartz Med Advantage Value (HMO) in 2025, please refer to our full plan details page.
Gundersen MN Quartz Med Advantage Value (HMO) is a HMO plan offered by University of Wisconsin Hospitals and Clincs Autho available for enrollment in 2025 to people living in Counties: Fillmore, Houston, Wabasha, Winona. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Gundersen MN Quartz Med Advantage Value (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Gundersen MN Quartz Med Advantage 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 Gundersen MN Quartz Med Advantage 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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3450.00 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
Prescription drugs are not covered by Gundersen MN Quartz Med Advantage Value (HMO).
Additional Benefits
The Gundersen MN Quartz Med Advantage Value (HMO) plan offers a range of benefits with varying cost-sharing. Hospital stays have a copay, while outpatient services and home health services often have no copay. Primary care visits have a $15 copay, and specialist visits have a $45 copay. This plan also includes coverage for hearing, vision, and dental services, with copays and maximum annual benefits. Emergency services and ambulance services have copays, and there are also benefits for medical equipment, diagnostic services, and therapies. The plan also covers some over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization. For days 1-6, the copay is $225, and there is no copay for days 7-90. Additional days for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay of $0.00 - $200.00, observation services, and ambulatory surgical center (ASC) services with no copay. Outpatient substance abuse services, including individual and group sessions, have a copay of $40.00. Outpatient blood services are also covered, including services not usually covered by Medicare plans.
Partial Hospitalization See details
Partial hospitalization is covered under the Gundersen MN Quartz Med Advantage Value (HMO) plan. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
The Gundersen MN Quartz Med Advantage Value (HMO) plan covers ambulance services with a $300 copay for both ground and air ambulance services, with no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered under the Gundersen MN Quartz Med Advantage Value (HMO) plan. Emergency Services have a $140 copay, Urgently Needed Services have a $40 copay, Worldwide Emergency Coverage has a $140 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $300 copay; all services have no coinsurance.
Primary Care See details
The Gundersen MN Quartz Med Advantage Value (HMO) plan covers Primary Care Physician Services and Chiropractic Services with a $15 copay, Physician Specialist Services with a $45 copay, and Occupational Therapy Services, Physical Therapy, and Speech-Language Pathology Services with a $30 copay. Mental Health Specialty Services and Psychiatric Services have a $40 copay for individual and group sessions, and Additional Telehealth Benefits have a copay ranging from $0 to $45. Podiatry Services and Other Health Care Professional services are covered, with copays that vary.
Preventive Services See details
The Gundersen MN Quartz Med Advantage Value (HMO) plan covers preventive services, including Medicare-covered services with no copay, annual physical exams, and additional preventive services. Therapeutic massage has a $15 copay, and fitness benefits cover memory fitness up to $200 per year. Health education, in-home safety assessments, personal emergency response systems, wigs for hair loss, weight management programs, alternative therapies, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers, additional smoking cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices, and modifications are not covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $15 copay, and prescription hearing aids with a maximum benefit of $1250 every two years, while fitting/evaluation for hearing aids, prescription hearing aids - inner ear, prescription hearing aids - outer ear, prescription hearing aids - over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $25 copay, and eyewear with a combined maximum benefit of $200 per year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental services include coverage for Medicare dental services with a $40 copay, and other dental services with a $350 maximum benefit per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), implant services, and oral and maxillofacial surgery are covered. However, maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the Gundersen MN Quartz Med Advantage Value (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 and no copay, Prosthetics/Medical Supplies with 20% coinsurance and no copay, and Diabetic Equipment. The plan does not cover Durable Medical Equipment for use outside the home.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services, are covered. Diagnostic Procedures/Tests have an $8 copay, Lab Services have a $10 copay, Diagnostic Radiological Services have a minimum $85 copay, Therapeutic Radiological Services have a minimum $45 copay, and Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by the Gundersen MN Quartz Med Advantage Value (HMO) plan with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, and SET for PAD Services have a copay of $25, while Pulmonary Rehabilitation Services have a copay of $20.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Gundersen MN Quartz Med Advantage Value (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $150 per day; additional and non-Medicare-covered SNF days are not covered.
Other Services See details
The "Other Services" benefit for Gundersen MN Quartz Med Advantage Value (HMO) covers over-the-counter (OTC) items, with a maximum benefit coverage amount of $20.00 every three months, and it offers nicotine replacement therapy (NRT). Acupuncture, meal benefits, dual eligible SNPs, 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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