Harp Enterprises, Inc.: Plan 1 PPO Plan - Summary of Benefits and Coverage
Plan Information
- Employer: Harp Enterprises, Inc.
- Plan Name: Plan 1 PPO Plan
- Plan Type: PPO (Preferred Provider Organization)
- Coverage: Employee & Dependents
- Coverage Period: October 1, 2025 – September 30, 2026
- Version: v1.0
- Contact Number: 1-888-832-0354
- Provider Search: provider-search.kariashealth.com
- Care Concierge: Karias Care Concierge at 888-832-0354
- Prescription Drug Information: hpiTPA.com
Important Plan Details
Overall Deductible
In-Network:
- Single Plan: $2,000 per employee
- Family Plan: $2,000 per person / $4,000 family maximum
Out-of-Network:
- Single Plan: $16,500 per employee
- Family Plan: $16,500 per person / $33,000 family maximum
Note: 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.
Out-of-Pocket Limit
In-Network:
- Single Plan: $2,000 per employee
- Family Plan: $2,000 per person / $4,000 family maximum
Out-of-Network:
- Single Plan: $22,500 per employee
- Family Plan: $22,500 per person / $45,000 family maximum
Note: The out-of-pocket limit is the most you could pay in a year for covered services.
What's NOT Included in Out-of-Pocket Limit
- Premiums
- Balance-billing charges
- Health care services the plan doesn't cover
Services Covered Before Meeting Deductible
- In-network preventive services
- Physician office visits
Network Requirements
- Referrals for Specialists: Not required - you may see a specialist without a referral
- Network Savings: Yes, you pay less when using in-network providers
- Balance Billing Risk: You may receive bills for the difference between provider charges and plan payments when using out-of-network providers
Special Calendar Year Note
For the calendar year starting January 1, 2025, any Deductible & Out-of-Pocket Limit expenses incurred during January 1, 2025 through September 30, 2025 shall be credited and used to satisfy the Deductible & Out-of-Pocket Limit for the calendar year ending December 31, 2025.
Detailed Coverage and Cost-Sharing
Office and Clinic Visits
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Primary Care Visit (injury/illness) | $25 copay per visit; deductible waived | 50% coinsurance | May have to pay for non-preventive services |
| Specialist Visit | $50 copay per visit; deductible waived | 50% coinsurance | Ask provider if services are preventive |
| Preventive Care/Screening/Immunization | No charge; deductible waived | 50% coinsurance | Covered preventive services listed at healthcare.gov/coverage/preventive-care-benefits/ |
Diagnostic Testing
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Diagnostic Test (x-ray, blood work) | Deductible only | 50% coinsurance | None |
| Imaging (CT/PET scans, MRIs) | Deductible only | 50% coinsurance | None |
Prescription Drug Coverage
Generic Drugs:
- Retail (30 days): $10 copay per script
- Retail/Mail Order (90 days): $20 copay per script
- Out-of-Network: Not covered
- Deductible does not apply
Preferred Brand Drugs:
- Retail (30 days): $35 copay per script
- Retail/Mail Order (90 days): $88 copay per script
- Out-of-Network: Not covered
- Deductible does not apply
Non-Preferred Brand Drugs:
- Retail (30 days): $70 copay per script
- Retail/Mail Order (90 days): $175 copay per script
- Out-of-Network: Not covered
- Deductible does not apply
Specialty Drugs (Retail/Mail Order 30 days):
- Tier 1: 25% coinsurance ($400 maximum)
- Tier 2: 20% coinsurance ($550 maximum)
- Tier 3: 20% coinsurance ($2,000 maximum)
- Tier 4: 20% coinsurance
- Tier 5: 50% coinsurance
- Out-of-Network: Not covered
- Deductible does not apply
- Refer to plan document for coverage requirements and other limitations related to specialty drugs
Outpatient Surgery
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Facility Fee (e.g., ambulatory surgery center) | Deductible only | 50% coinsurance | None |
| Physician/Surgeon Fees | Deductible only | 50% coinsurance | None |
Emergency and Urgent Care
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Emergency Room Care | In-Network deductible then $500 copay per visit | In-Network deductible then $500 copay per visit | Copay waived if admitted |
| Emergency Medical Transportation | In-Network deductible then $500 copay per visit | In-Network deductible then $500 copay per visit | None |
| Urgent Care | $25 copay per visit; deductible waived | 50% coinsurance | None |
Hospital Stay
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Facility Fee (e.g., 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 Visits | $25 copay per visit; deductible waived | 50% coinsurance | Preauthorization required for inpatient services |
| Outpatient Services - Intensive Outpatient Treatment | No charge; deductible waived | 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 hours (normal delivery) / 96 hours (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 | 100 visits per year |
| Rehabilitation Services - Inpatient | Deductible only | 50% coinsurance | 150 days per year with skilled nursing care; Preauthorization required |
| Rehabilitation Services - Outpatient | $25 copay per visit; deductible waived | 50% coinsurance | 25 visits per year each for Occupational, Physical, and Speech therapies |
| Habilitation Services - Early Intervention | $25 copay per visit; deductible waived | 50% coinsurance | Coverage to age 3 |
| Habilitation Services - Developmental Delay | $25 copay per visit; deductible waived | 50% coinsurance | Preauthorization and visit limits based on services provided |
| Skilled Nursing Care | Deductible only | 50% coinsurance | 150 days per year with inpatient rehab; Preauthorization required |
| Durable Medical Equipment | Deductible only | 50% coinsurance | Preauthorization required; See plan for limitations |
| Hospice Services | No charge; deductible waived | 50% coinsurance | Preauthorization required for inpatient services |
Children's Dental and Vision Care
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Children's Eye Exam | Not covered | Not covered | N/A |
| Children's Glasses | Not covered | Not covered | N/A |
| Children's Dental Check-up | Not covered | Not covered | N/A |
Excluded Services
The following services are generally NOT covered by this plan:
- Acupuncture
- Dental care (adult and child)
- Non-emergency care when traveling outside the U.S.
- Weight loss programs
- Bariatric surgery
- Infertility treatment
- Routine eye care (adult and child)
- Cosmetic surgery
- Long-term care
- Routine foot care
Other Covered Services
The following services are covered with limitations:
- Chiropractic Care: 20 visits per year
- Hearing Aids: 1 aid per ear per 36 months
- Private Duty Nursing: Limited to a home setting, 2,000 hours per year
Coverage Examples
Example 1: Peg is Having a Baby
9 months of in-network prenatal 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
Peg Would Pay:
- Deductibles: $2,000
- Copayments: $0
- Coinsurance: $0
- Limits or exclusions: $60
- Total: $2,060
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
Mia Would Pay:
- Deductibles: $1,700
- Copayments: $300
- Coinsurance: $0
- Limits or exclusions: $0
- Total: $2,000
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
Joe Would Pay:
- Deductibles: $900
- Copayments: $600
- Coinsurance: $0
- Limits or exclusions: $20
- Total: $1,520
Note: These are examples only. Your actual costs will differ depending on the actual care you receive, the prices your providers charge, and many other factors. These examples are based on self-only coverage.
Important Rights and Information
Minimum Essential Coverage
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage.
Minimum Value Standards
Does this plan meet Minimum Value Standards? Yes
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Rights to Continue Coverage
If you want to continue your coverage after it ends, contact:
- U.S. Department of Labor, Employee Benefits Security Administration
- Phone: 1-866-444-EBSA (3272)
- Website: www.dol.gov/ebsa/healthreform
You may also purchase individual insurance coverage through the Health Insurance Marketplace:
- Website: www.HealthCare.gov
- Phone: 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
- Review your explanation of benefits for the medical claim
- Consult your plan documents for complete information on submitting claims, appeals, or grievances
- Contact U.S. Department of Labor: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
Language Access Services
- Spanish (Español): Para obtener asistencia en Español, llame al 1-888-832-0354
- Portuguese (Português): De assistência em Português, 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
Important Definitions
For definitions of common terms such as:
- Allowed amount
- Balance billing
- Coinsurance
- Copayment
- Deductible
- Provider
- Other underlined terms
Visit: healthcare.gov/sbc-glossary or call 1-888-832-0354 to request a copy of the Glossary.
Additional Resources
- Complete Terms of Coverage: Call 1-888-832-0354
- Provider Search: provider-search.kariashealth.com
- Prescription Drug Coverage: hpiTPA.com
- Preventive Care Services List: healthcare.gov/coverage/preventive-care-benefits/
This is a summary only. For complete information about your coverage or to get a copy of the complete terms of coverage, call 1-888-832-0354.