2020 Plans

 

ELITE

VALUE D

ELITE D

 This plan does not include prescription drug coverage.This plan includes prescription drug coverage.This plan includes prescription drug coverage.
Monthly Premium$0$0$27.60
Annual Out-of-Pocket Maximum (does not include prescription drugs)$4,500$5,900$4,500
Office Visit (Personal physician/specialist)

Primary Care Provider: $10 copay/visit
Specialist: $35 copay/visit

Primary Care Provider: $10 copay/visit

Specialist: $35 copay/visit

Primary Care Provider: $10 copay/visit

Specialist: $35 copay/visit

Urgent Care (worldwide)SwedishAmerican Urgent Care: $0 copay
Participating Urgent Care: $35 copay/visit
Non-Participating Urgent Care: $45 copay/visit
SwedishAmerican Urgent Care: $0 copay
Participating Urgent Care: $35 copay/visit
Non-Participating Urgent Care: $50 copay/visit
SwedishAmerican Urgent Care: $0 copay
Participating Urgent Care: $35 copay/visit
Non-Participating Urgent Care: $45 copay/visit
Emergency (worldwide)$90 copay/visit$90 copay/visit$90 copay/visit
Lab and X-rayYou pay up to 20%You pay up to 20%You pay up to 20%
Inpatient Hospital CoverageDays 1-7: $275 copay/day
Days 8 & beyond: $0
Days 1-5: $380 copay
Days 6 & beyond: $0
Days 1-7: $275 copay
Days 8 & beyond: $0
Skilled nursing facility (an initial 3-day hospital stay required)Days 1-20: $0
Days 21-100: $170 copay/day
Days 1-20: $0
Days 21-100: $170 copay/day
Days 1-20: $0
Days 21-100: $170 copay/day
VisionInitial routine eye exam: $25
Initial routine eye exam: $25Initial routine eye exam: $25
HearingHearing exam: $25
Hearing aids: $700-$1,050 copay/aid
Limit: 1 per ear/year
Hearing exam: $25
Hearing aids: $700-$1,050 copay/aid
Limit: 1 per ear/year
Hearing exam: $25
Hearing aids: $700-$1,050 copay/aid
Limit: 1 per ear/year
Outpatient Surgery$0 - $275 copay$0-$370 copay$0-$275 copay
Preventive ServicesCovered in fullCovered in fullCovered in full
Coverage Documents

2020 Summary of Benefits
2020 Evidence of Coverage
2020 Annual Notice of Changes

2020 Summary of Benefits
2020 Evidence of Coverage

2020 Annual Notice of Changes

2020 Summary of Benefits
2020 Evidence of Coverage
2020 Annual Notice of Changes

More benefit details are available in each plan's Summary of Benefits, or if you're a member, your plan's Evidence of Coverage document.

Copayment and coinsurance amounts shown are what the member pays.

Whether you’re new to Medicare or want to see what’s available, you’ll find Quartz Medicare Advantage (HMO) offers Medicare Advantage plan options that cover everything Original Medicare covers and more. Quartz Medicare Advantage plans include extra benefits such as an integrative wellness platform, over-the-counter benefit cards and post-hospital stay meal delivery.

As of January 1, 2020, Quartz Medicare Advantage has one provider network, which means you can see any participating provider in the entire Quartz Medicare Advantage network in Wisconsin, Iowa, Minnesota and Illinois. However, you will need to keep your eligibility in the county service area for the plan you have enrolled.

Do you have questions about Medicare or Quartz Medicare Advantage? We have answers. Call Customer Service at (800) 394-5566; TTY 711 or (800) 877-8973.

Out-of-network providers

In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. These are the three exceptions:

1. The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 in the Evidence of Coverage (links to the Evidence of Coverage documents can be found above).

2. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. If your network provider suggests or recommends care out-of-network, a referral must be obtained in writing, and signed by the plan’s medical director prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider.

3. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

Using a pharmacy that is out of the network

If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

  • Part D vaccines administered in a clinic or hospital setting that are considered out-of-network.
  • Part D drugs which cannot be obtained from a network pharmacy in a timely manner, such as no network pharmacy available in a reasonable driving distance or that provides 24-hour, 7-day a week service.
  • Part D drugs which are not obtainable at a network pharmacy because they are only available from specialty pharmacies or typically shipped directly from the manufacturer.
  • Part D drugs dispensed while in an emergency department, provider-based clinic, or an outpatient setting and a network pharmacy is unavailable.
  • During any Federal disaster declaration or other public health emergency declaration in which you are evacuated or displaced.

Interpreter Services

Interpreter Services can be found here. We have interpreter services available to answer questions about our health and drug plan. To get an interpreter, call Customer Service. This is a free service.  

Contact Information

If you have questions or concerns, please call Customer Service.

Disclaimers

Quartz Medicare Advantage is an HMO plan with a Medicare contract. Enrollment in this plan depends on contract renewal. Quartz Medicare Advantage & Part D contracts are reviewed annually by The Centers for Medicare and Medicaid Services to determine renewal status of the plan. You must continue to pay your Medicare Part B premium. The benefit information provided herein is a brief summary, not a comprehensive description of benefits.  Members must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. For more information contact the plan.

Quartz Medicare Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

This webpage was updated on May 26, 2020.