Five Star Technology Solutions: Plan 36 - Summary of Benefits and Coverage
Plan Overview
Coverage Period: October 1, 2025 – September 30, 2026
Plan Type: QHDHP-PPO (Qualified High Deductible Health Plan - PPO)
Coverage For: Employee & Dependents
Contact: 1-888-832-0354
Provider Search: provider-search.kariashealth.com
Karias Care Concierge: 888-832-0354
Prescription Drug Information: hpiTPA.com
Key Plan Features
Overall Deductible
In-Network:
- Single Plan: $5,500 per employee
- Family Plan: $5,500 per person / $11,000 family
Out-of-Network:
- Single Plan: $11,000 per employee
- Family Plan: $11,000 per person / $22,000 family
Important Note: Generally, you must pay all costs from providers up to the deductible amount before this plan begins to pay. For family plans, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Services Covered Before Meeting Deductible
Yes, certain services are covered before you meet your deductible:
- In-network preventive services
These services may have a copayment or coinsurance. The plan covers certain preventive services without cost sharing and before you meet your deductible.
Important Difference: Unlike other plans, regular physician office visits are NOT covered before meeting the deductible in this QHDHP plan.
Out-of-Pocket Limit
In-Network:
- Single Plan: $5,500 per employee
- Family Plan: $5,500 per person / $11,000 family
Out-of-Network:
- Single Plan: $11,000 per employee
- Family Plan: $11,000 per person / $22,000 family
What This Means: The out-of-pocket limit is the most you could pay in a year for covered services. Family members must meet their own out-of-pocket limits until the overall family out-of-pocket limit is met.
Note: In this QHDHP plan, the out-of-pocket limit is the same as the deductible, meaning once you meet your deductible, you've reached your out-of-pocket maximum for in-network services.
What's NOT Included in Out-of-Pocket Limit
- Premiums
- Balance billing charges
- Health care services this plan doesn't cover
Network Provider Benefits
Do You Pay Less with Network Providers? Yes. This plan uses a provider network. You pay less if you use a provider in the plan's network. You pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing).
Important: Your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Specialist Referrals
Do You Need a Referral? No. You may see a specialist you choose without a referral.
Special Carryover Provision
For the Calendar Year starting January 1, 2025, any Deductible & Out-of-Pocket expenses incurred during the period January 1, 2025 through September 30, 2025 shall be credited and used to satisfy the Deductible & Out-of-Pocket for the Calendar Year starting January 1, 2025 and ending December 31, 2025.
Detailed Coverage and Costs
Note: All copayment and coinsurance costs shown are after your deductible has been met, if a deductible applies.
IMPORTANT: This is a High Deductible Health Plan (QHDHP). Most services require you to pay the full deductible first, with no copays. After meeting the deductible, covered services are paid at 100% in-network.
Office and Clinic Visits
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Primary care visit (injury/illness) | Deductible only | 50% coinsurance | You may have to pay for services that aren't preventive. Ask your provider if services are preventive, then check what your plan will pay. |
| Specialist visit | Deductible only | 50% coinsurance | Same as above |
| Preventive care/screening/immunization | No charge; deductible waived | 50% coinsurance | Same as above |
Testing and Imaging
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Diagnostic test (x-ray, blood work) | Deductible only | 50% coinsurance | None |
| Imaging (CT/PET scan, MRI) | Deductible only | 50% coinsurance | None |
Prescription Drugs
More information available at: hpiTPA.com
| Drug Type | Retail (30-day supply) | Retail/Mail Order (90-day supply) | Out-of-Network |
|---|---|---|---|
| Generic drugs | Deductible only | Deductible only | Not covered |
| Preferred brand drugs | Deductible only | Deductible only | Not covered |
| Non-preferred brand drugs | Deductible only | Deductible only | Not covered |
| Specialty drugs | Deductible only | Deductible only | Not covered |
Important Notes:
- Deductible DOES apply to prescription drugs (unlike other plans)
- Preventive Care medications are NOT subject to the Deductible
- See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs
Outpatient Surgery
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Facility fee (ambulatory surgical center) | Deductible only | 50% coinsurance | None |
| Physician/surgeon fees | Deductible only | 50% coinsurance | None |
Immediate Medical Attention
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Emergency room care | In-Network deductible only | In-Network deductible only | None |
| Emergency medical transportation | Deductible only | 50% coinsurance | None |
| Urgent care | Deductible only | 50% coinsurance | None |
Hospital Stay
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Facility fee (hospital room) | Deductible only | 50% coinsurance | Preauthorization required |
| Physician/surgeon fees | Deductible only | 50% coinsurance | Preauthorization required |
Mental Health, Behavioral Health, and Substance Abuse Services
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Outpatient services - Office visit | Deductible only | 50% coinsurance | Preauthorization required for Inpatient services |
| Outpatient services - Intensive outpatient treatment | Deductible only | 50% coinsurance | Preauthorization required for Inpatient services |
| Inpatient services | Deductible only | 50% coinsurance | Preauthorization required |
Pregnancy and Maternity Care
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Office visits - Prenatal Care | No charge; deductible waived | 50% coinsurance | Maternity care may include tests and services described elsewhere in SBC |
| Office visits - Postnatal Care | Deductible only | 50% coinsurance | Requires preauthorization for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) |
| Childbirth/delivery professional services | Deductible only | 50% coinsurance | Same as above |
| Childbirth/delivery facility services | Deductible only | 50% coinsurance | Same as above |
Recovery and Special Health Needs
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Home health care | Deductible only | 50% coinsurance | 60 visits per year |
| Rehabilitation services - Inpatient | Deductible only | 50% coinsurance | Preauthorization required for Inpatient |
| Rehabilitation services - Outpatient | Deductible only | 50% coinsurance | 20 visits per year each for Occupational, Speech and Physical therapies |
| Habilitation services - Early Intervention | Deductible only | 50% coinsurance | To age 3; Preauthorization & visit limits based on provided services |
| Habilitation services - Developmental Delay | Deductible only | 50% coinsurance | Preauthorization & visit limits based on provided services |
| Skilled nursing care | Deductible only | 50% coinsurance | 60 days per year; Preauthorization required |
| Durable medical equipment | Deductible only | 50% coinsurance | Please refer to plan document for items requiring preauthorization |
| Hospice services | Deductible only | 50% coinsurance | Preauthorization required for Inpatient |
Child Dental and Eye Care
| Service | In-Network Cost | Out-of-Network Cost |
|---|---|---|
| Children's eye exam | Not covered | Not covered |
| Children's glasses | Not covered | Not covered |
| Children's dental check-up | Not covered | Not covered |
Excluded Services
Services Your Plan Generally Does NOT Cover:
- Acupuncture
- Hearing aids
- Non-emergency care when traveling outside U.S.
- Routine foot care
- Bariatric Surgery
- Infertility Treatment
- Private Duty Nursing
- Weight loss programs
- Dental care (routine child & adult)
- Long term care
- Routine eye care (child & adult)
Other Covered Services
Limitations may apply to these services. This isn't a complete list. Please see your plan document.
- Chiropractic care (20 visits per year)
Coverage Examples
Example 1: Peg is Having a Baby
9 months of in-network pre-natal care and a hospital delivery
Services Included:
- Specialist office visits (prenatal care)
- Childbirth/Delivery Professional Services
- Childbirth/Delivery Facility Services
- Diagnostic tests (ultrasounds and blood work)
- Specialist visit (anesthesia)
Total Example Cost: $12,700
What Peg Would Pay:
- Deductibles: $5,500
- Copayments: $0
- Coinsurance: $0
- Limits or exclusions: $60
- Total Peg would pay: $5,560
Example 2: Mia's Simple Fracture
In-network emergency room visit and follow up care
Services Included:
- Emergency room care (including medical supplies)
- Diagnostic test (x-ray)
- Durable medical equipment (crutches)
- Rehabilitation services (physical therapy)
Total Example Cost: $2,800
What Mia Would Pay:
- Deductibles: $2,400
- Copayments: $0
- Coinsurance: $0
- Limits or exclusions: $0
- Total Mia would pay: $2,400
Example 3: Managing Joe's Type 2 Diabetes
A year of routine in-network care of a well-controlled condition
Services Included:
- Primary care physician office visits (including disease education)
- Diagnostic tests (blood work)
- Prescription drugs
- Durable medical equipment (glucose meter)
Total Example Cost: $5,600
What Joe Would Pay:
- Deductibles: $4,600
- Copayments: $0
- Coinsurance: $0
- Limits or exclusions: $20
- Total Joe would pay: $4,620
Important Note: These are not cost estimators. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. These coverage examples are based on self-only coverage.
Your Rights and Additional Information
Rights to Continue Coverage
Agencies that can help if you want to continue your coverage after it ends:
- Department of Labor's Employee Benefits Security Administration: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
- Health Insurance Marketplace: www.HealthCare.gov or 1-800-318-2596
Grievance and Appeals Rights
If you have a complaint against your plan for a denial of a claim (called a grievance or appeal):
- Contact the plan: 1-888-832-0354
- U.S. Department of Labor's Employee Benefits Security Administration: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
- Review your explanation of benefits and plan documents for complete information
Minimum Essential Coverage
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Value Standards
Does this plan meet Minimum Value Standards? Yes.
Language Access Services
- Spanish (Español): Para obtener asistencia en Español, llame al 1-888-832-0354
- Portuguese (Portuguès): De assistència em Portuguès, ligue 1-888-832-0354
- Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-888-832-0354
Understanding This High Deductible Health Plan (QHDHP)
What Makes This Plan Different?
This is a Qualified High Deductible Health Plan (QHDHP), which works differently from traditional PPO plans:
- Higher Deductible: You pay more upfront ($5,500 for single coverage) before the plan starts paying
- No Copays: Most services don't have copays - you pay the full cost until you meet your deductible
- 100% Coverage After Deductible: Once you meet your deductible, in-network covered services are paid at 100%
- HSA Eligible: This plan qualifies you to contribute to a Health Savings Account (HSA), which offers tax advantages
- Deductible = Out-of-Pocket Max: For in-network services, once you hit your deductible, you've reached your maximum out-of-pocket cost
Who Should Consider This Plan?
- Individuals who are generally healthy and don't need frequent medical care
- Those who want to maximize HSA contributions for tax savings
- People who can afford to pay higher upfront costs if needed
- Those looking for lower monthly premiums
Quick Reference
Plan Contact Information:
- Phone: 1-888-832-0354
- Provider Search: provider-search.kariashealth.com
- Karias Care Concierge: 888-832-0354
- Prescription Drug Info: hpiTPA.com
Key Cost-Sharing Summary:
- In-Network Deductible (Single): $5,500
- In-Network Out-of-Pocket Max (Single): $5,500 (same as deductible)
- Primary Care: Deductible only (no copay)
- Specialist: Deductible only (no copay)
- Hospital: Deductible only (no copay)
- Emergency Room: Deductible only (no copay)
- Prescription Drugs: Deductible applies (except preventive medications)
After Deductible is Met: In-network covered services are paid at 100%
Document Version: v1.0
Effective Date: October 1, 2025