HSA Base Plan (CIGNA) - Complete Coverage Guide

Plan Overview

Plan Name: HSA Base Plan (CIGNA)
Employer: Matrix Sciences International Inc.
Coverage Period: January 1, 2026 – December 31, 2026
Plan Type: QHDHP-PPO (Qualified High Deductible Health Plan - Preferred Provider Organization)
Coverage For: Employee & Dependents
Customer Service: 1-888-832-0354
Provider Search: provider-search.kariashealth.com
Care Concierge: Karias Care Concierge at 1-888-832-0354
Prescription Drug Information: hpiTPA.com

Key Plan Features at a Glance

Deductibles

In-Network:

Single Plan: $3,400 per employee
Family Plan: $3,400 per person / $6,800 family maximum

Out-of-Network:

Single Plan: $10,200 per employee
Family Plan: $10,200 per person / $20,400 family maximum

Important Notes:

Generally, you must pay all costs from providers up to the deductible amount before the plan begins to pay
For family plans, each family member must meet their own individual deductible until the total deductible expenses paid by all family members meets the overall family deductible
No specific service deductibles apply

Out-of-Pocket Limits

In-Network:

Single Plan: $3,400 per employee
Family Plan: $3,400 per person / $6,800 family maximum

Out-of-Network:

Single Plan: $20,400 per employee
Family Plan: $20,400 per person / $40,800 family maximum

What's NOT Included in Out-of-Pocket Limit:

Premiums
Balance billing charges
Health care services this plan doesn't cover

Important Note: The out-of-pocket limit is the maximum 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.

Services Covered Before Deductible

Yes - In-network preventive services are covered before you meet your deductible. This includes certain preventive services without cost sharing. For a complete list, visit healthcare.gov/coverage/preventive-care-benefits.

Network Requirements

Referrals: No referral needed to see a specialist. You may see any specialist you choose.

Network Usage: Yes, you pay less when using network providers. Using out-of-network providers results in higher costs and potential balance billing (the difference between the provider's charge and what the plan pays).

Important Warning: Network providers might use out-of-network providers for some services (such as lab work). Always check with your provider before receiving services.

Detailed Coverage Breakdown

Office Visits & Clinic Care

Primary Care Visit (Injury or Illness)

In-Network: Deductible only (after deductible is met, plan covers remaining costs)
Out-of-Network: 40% coinsurance (you pay 40% after deductible)
Notes: 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

In-Network: Deductible only
Out-of-Network: 40% coinsurance

Preventive Care/Screening/Immunization

In-Network: No charge; deductible waived
Out-of-Network: 40% coinsurance
Notes: Ask your provider if the services are preventive to avoid unexpected costs

Diagnostic Testing & Imaging

Diagnostic Tests (X-ray, Blood Work)

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Limitations: None

Imaging (CT/PET Scans, MRIs)

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Limitations: None

Prescription Drug Coverage

More Information Available at: hpiTPA.com

Deductible Application: Deductible applies to all prescription drugs except Preventive Care medications

Insulin Cost Cap: Your cost for a covered insulin drug will not exceed $100 per 30-day supply

Generic Drugs

In-Network Retail (30 days): Deductible only
In-Network Mail Order (90 days): Deductible only
Out-of-Network Retail (30 days): Additional 50% coinsurance, subject to Allowed Amount

Preferred Brand Drugs

In-Network Retail (30 days): Deductible only
In-Network Mail Order (90 days): Deductible only
Out-of-Network Retail (30 days): Additional 50% coinsurance, subject to Allowed Amount

Non-Preferred Brand Drugs

In-Network Retail (30 days): Deductible only
In-Network Mail Order (90 days): Deductible only
Out-of-Network Retail (30 days): Additional 50% coinsurance, subject to Allowed Amount

Specialty Drugs

In-Network Retail Only (30 days): Deductible only
Out-of-Network: Additional 50% coinsurance, subject to Allowed Amount
Special Notes: See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs

Surgical Services

Outpatient Surgery - Facility Fee (e.g., Ambulatory Surgery Center)

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Limitations: None

Outpatient Surgery - Physician/Surgeon Fees

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Limitations: None

Emergency & Urgent Care

Emergency Room Care

In-Network: In-network deductible only
Out-of-Network: In-network deductible only (same as in-network)
Limitations: None

Emergency Medical Transportation

In-Network: In-network deductible only
Out-of-Network: In-network deductible only (same as in-network)
Limitations: None

Urgent Care

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Limitations: None

Hospital Stays (Inpatient Care)

Facility Fee (e.g., Hospital Room)

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Important: Preauthorization required

Physician/Surgeon Fees

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Important: Preauthorization required

Mental Health, Behavioral Health & Substance Abuse Services

Outpatient Services

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Preauthorization: Required for Inpatient services

Inpatient Services

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Preauthorization: Required for Inpatient services

Pregnancy & Maternity Care

Prenatal Care Office Visits

In-Network: No charge; deductible waived
Out-of-Network: 40% coinsurance

Postnatal Care Office Visits

In-Network: Deductible only
Out-of-Network: 40% coinsurance

Childbirth/Delivery Professional Services

In-Network: Deductible only
Out-of-Network: 40% coinsurance

Childbirth/Delivery Facility Services

In-Network: Deductible only
Out-of-Network: 40% coinsurance

Important Notes:

Maternity care may include tests and services described elsewhere in this SBC
Preauthorization required for stays over 48 hours (normal delivery) or 96 hours (caesarean delivery)

Recovery & Special Health Needs

Home Health Care

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Limitations: None

Rehabilitation Services

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Important: Preauthorization required for Inpatient

Habilitation Services

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Special Coverage: Early intervention to age 3
Important: Preauthorization and visit limits based on services provided for Learning Deficiencies, Behavioral Problems/Developmental Delays

Skilled Nursing Care

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Important: Preauthorization required

Durable Medical Equipment

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Important: Please refer to plan document for items requiring preauthorization

Hospice Services

In-Network: Deductible only
Out-of-Network: 40% coinsurance
Important: Preauthorization required for Inpatient

Vision & Dental Care for Children

Children's Eye Exam

Coverage: Not covered
In-Network: Not covered
Out-of-Network: Not covered

Children's Glasses

Coverage: Not covered
In-Network: Not covered
Out-of-Network: Not covered

Children's Dental Check-up

Coverage: Not covered
In-Network: Not covered
Out-of-Network: Not covered

Services NOT Covered by This Plan

The following services are generally NOT covered. Check your policy or plan document for more information and a complete list of excluded services:

Acupuncture
Long-term care
Routine foot care
Cosmetic surgery
Non-emergency care when traveling outside U.S.
Weight loss programs
Dental care (routine child & adult)
Routine eye care (adult & child)

Other Covered Services (Limitations Apply)

This is not a complete list. Please see your plan document for full details.

Bariatric Surgery

Covered with limitations (refer to plan document)

Infertility Treatment

Coverage: Four (4) cycles maximum
Special Approval: Up to six (6) cycles per person, per calendar year

Chiropractic Care

Coverage: 30 visits per year

Private Duty Nursing

Covered with limitations (refer to plan document)

Hearing Aids

Under Age 18: 1 aid per ear per 24 months
Age 18 & Over: $2,500 per aid per ear per 24 months

Coverage Examples

These examples show how the plan might cover costs in specific medical situations. These are NOT cost estimators. Your actual costs will differ based on actual care received, provider charges, and other factors.

Example 1: Peg is Having a Baby

Scenario: 9 months of in-network prenatal care and 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's Costs:

Deductibles: $3,400
Copayments: $0
Coinsurance: $0
Limits or exclusions: $60
Total Peg Would Pay: $3,460

Plan's Deductibles Applied:

Overall deductible: $3,400
Specialist deductible: None
Hospital (facility) deductible: None
Other deductible: None

Example 2: Mia's Simple Fracture

Scenario: 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's Costs:

Deductibles: $2,400
Copayments: $0
Coinsurance: $0
Limits or exclusions: $400
Total Mia Would Pay: $2,800

Plan's Deductibles Applied:

Overall deductible: $3,400
Specialist deductible: None
Hospital (facility) deductible: None
Other deductible: None

Example 3: Managing Joe's Type 2 Diabetes

Scenario: A year of routine in-network care for 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's Costs:

Deductibles: $3,400
Copayments: $0
Coinsurance: $0
Limits or exclusions: $20
Total Joe Would Pay: $3,420

Plan's Deductibles Applied:

Overall deductible: $3,400
Specialist deductible: None
Hospital (facility) deductible: None
Other: No charge

Note: These coverage examples are based on self-only coverage.

Important Legal 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. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

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.

Your Rights & Resources

Rights to Continue Coverage

There are agencies that can help if you want to continue your coverage after it ends:

Department of Labor's Employee Benefits Security Administration
- Phone: 1-866-444-EBSA (3272)
- Website: www.dol.gov/ebsa/healthreform
Health Insurance Marketplace
- Other coverage options may be available, including buying 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):

Review the explanation of benefits you receive for the medical claim
Your plan documents provide complete information to submit a claim, appeal, or grievance
Contact the plan at 1-888-832-0354
Contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform

Language Access Services

Assistance is available in multiple languages:

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

Glossary of Common Terms

For definitions of common terms such as:

Allowed amount
Balance billing
Coinsurance
Copayment
Deductible
Provider
And other underlined terms

Visit: healthcare.gov/sbc-glossary
Or Call: 1-888-832-0354 to request a copy

Quick Reference Contact Information

Purpose	Contact Information
General Plan Questions	1-888-832-0354
Provider Search	provider-search.kariashealth.com
Karias Care Concierge	1-888-832-0354
Prescription Drug Info	hpiTPA.com
Complete Terms of Coverage	1-888-832-0354
Grievances & Appeals	1-888-832-0354
DOL Employee Benefits	1-866-444-EBSA (3272)
Health Insurance Marketplace	1-800-318-2596

Important Reminders for Support Team

Deductible Structure: This is a high deductible health plan. Most services require meeting the deductible first before the plan pays, EXCEPT preventive care which is covered at no charge in-network.
Out-of-Network Costs: Out-of-network services have significantly higher deductibles and coinsurance (40% after deductible). Always encourage use of in-network providers.
Preauthorization Requirements: Several services require preauthorization:
- Hospital stays
- Inpatient mental health/substance abuse
- Inpatient rehabilitation
- Skilled nursing care
- Inpatient hospice
- Maternity stays over 48/96 hours
- Certain durable medical equipment
- Habilitation services for learning deficiencies
Emergency Services: Emergency room care and emergency medical transportation are covered at the in-network deductible rate even if out-of-network.
Insulin Cap: Special cost cap of $100 per 30-day supply for insulin.
Premium Information: Premium costs are provided separately and not included in this SBC.
Provider Network Verification: Always remind customers to verify providers are in-network and check if the provider uses out-of-network services (like labs).

Document Version: v1.0
Last Updated: Effective Date 01/01/2026
Document Pages: 5 pages total