Skip to content
English
Contact us
  • There are no suggestions because the search field is empty.

HSA Low Plan (CIGNA) - Complete Coverage Guide

This knowledge base article covers the Matrix Sciences International Inc. HSA Low Plan, a Qualified High Deductible Health Plan (QHDHP-PPO) effective from January 1, 2026, to December 31, 2026. The plan provides coverage for employees and dependents with in-network and out-of-network options, featuring deductibles ranging from $3,500 to $7,000 for individuals, coinsurance structures of 20% in-network and 40% out-of-network, and comprehensive coverage for medical services, prescription drugs (with $100 insulin cap), maternity care, mental health services, and more.

Plan Overview

Plan Name: HSA Low Plan
Insurance Provider: CIGNA
Employer: Matrix Sciences International Inc.
Plan Type: QHDHP-PPO (Qualified High Deductible Health Plan - Preferred Provider Organization)
Coverage Period: January 1, 2026 – December 31, 2026
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

Deductibles

In-Network Deductible:

  • Single Plan: $3,500 per employee
  • Family Plan: $3,500 per person / $7,000 family maximum

Out-of-Network Deductible:

  • Single Plan: $7,000 per employee
  • Family Plan: $7,000 per person / $14,000 family maximum

Important Notes:

  • 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 amount paid by all family members meets the overall family deductible
  • No separate deductibles for specific services

Out-of-Pocket Limits

In-Network:

  • Single Plan: $7,000 per employee
  • Family Plan: $7,000 per person / $14,000 family maximum

Out-of-Network:

  • Single Plan: $21,000 per employee
  • Family Plan: $21,000 per person / $42,000 family maximum

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

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

Important: The out-of-pocket limit is the maximum you could pay in a year for covered services. For family plans, each member must meet their own out-of-pocket limit until the overall family out-of-pocket limit is met.

Network Benefits

Do You Need to Use Network Providers?

  • You pay LESS when using in-network providers
  • You pay the MOST when using out-of-network providers
  • Out-of-network providers may bill you for the difference between their charge and what the plan pays (balance billing)
  • Network providers might use out-of-network providers for some services (such as lab work) - always check before receiving services

Do You Need a Referral to See a Specialist?

  • NO - You may see any specialist you choose without a referral

Services Covered Before Meeting Deductible

YES - Some services are covered before you meet your deductible:

  • In-network preventive services (no charge, deductible waived)
  • Copayment or coinsurance may apply to other services
  • Full list of covered preventive services available at: healthcare.gov/coverage/preventive-care-benefits

Detailed Coverage Breakdown

Office Visits & Preventive Care

Primary Care Visit (injury or illness):

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Note: 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: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)

Preventive Care/Screening/Immunization:

  • In-Network: No charge; deductible waived
  • Out-of-Network: 40% coinsurance (after deductible)

Diagnostic Tests & Imaging

Diagnostic Tests (x-ray, blood work):

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Limitations: None

Imaging (CT/PET scans, MRIs):

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Limitations: None

Prescription Drug Coverage

Important Information:

  • More information available at hpiTPA.com
  • 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
  • See plan document for specialty drug coverage requirements and limitations

Generic Drugs:

  • Retail (30 days): 20% coinsurance (after deductible)
  • Mail Order (90 days): 20% coinsurance (after deductible)
  • Retail Only (30 days) Out-of-Network: Additional 50% coinsurance, subject to Allowed Amount

Preferred Brand Drugs:

  • Retail (30 days): 20% coinsurance (after deductible)
  • Mail Order (90 days): 20% coinsurance (after deductible)
  • Retail Only (30 days) Out-of-Network: Additional 50% coinsurance, subject to Allowed Amount

Non-Preferred Brand Drugs:

  • Retail (30 days): 20% coinsurance (after deductible)
  • Mail Order (90 days): 20% coinsurance (after deductible)
  • Retail Only (30 days) Out-of-Network: Additional 50% coinsurance, subject to Allowed Amount

Specialty Drugs:

  • Retail Only (30 days): 20% coinsurance (after deductible)
  • No mail order option available

Outpatient Surgery

Facility Fee (e.g., ambulatory surgery center):

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Limitations: None

Physician/Surgeon Fees:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Limitations: None

Emergency & Urgent Care

Emergency Room Care:

  • In-network deductible applies; then 20% coinsurance
  • Applies to both in-network and out-of-network facilities
  • Limitations: None

Emergency Medical Transportation:

  • In-network deductible applies; then 20% coinsurance
  • Applies to both in-network and out-of-network
  • Limitations: None

Urgent Care:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Limitations: None

Hospital Stays

Facility Fee (e.g., hospital room):

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Important: Preauthorization required

Physician/Surgeon Fees:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Important: Preauthorization required

Mental Health, Behavioral Health & Substance Abuse Services

Outpatient Services:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Preauthorization required for inpatient services

Inpatient Services:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Important: Preauthorization required for inpatient services

Maternity Care

Office Visits - Prenatal Care:

  • In-Network: No charge; deductible waived
  • Out-of-Network: 40% coinsurance (after deductible)

Office Visits - Postnatal Care:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)

Childbirth/Delivery Professional Services:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)

Childbirth/Delivery Facility Services:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)

Important Notes:

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

Recovery & Special Health Needs

Home Health Care:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Limitations: None

Rehabilitation Services:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Important: Preauthorization required for inpatient rehabilitation

Habilitation Services:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Coverage Details: 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: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Important: Preauthorization required

Durable Medical Equipment:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Important: Please refer to plan document for items requiring preauthorization

Hospice Services:

  • In-Network: 20% coinsurance (after deductible)
  • Out-of-Network: 40% coinsurance (after deductible)
  • Important: Preauthorization required for inpatient hospice

Children's Vision & Dental Care

Children's Eye Exam:

  • Not covered

Children's Glasses:

  • Not covered

Children's Dental Check-up:

  • Not covered

Excluded Services

The following services are NOT covered by this plan:

  1. Acupuncture
  2. Long-term care
  3. Routine foot care
  4. Cosmetic surgery
  5. Non-emergency care when traveling outside the U.S.
  6. Weight loss programs
  7. Dental care (routine child & adult)
  8. Routine eye care (adult & child)

Note: Check your policy or plan document for more information and a complete list of excluded services.

Other Covered Services

The following services ARE covered with limitations:

Bariatric Surgery:

  • Coverage with limitations (refer to plan document for details)

Infertility Treatment:

  • Four (4) cycles maximum with special approval
  • Up to six (6) cycles per person, per calendar year

Chiropractic Care:

  • 30 visits per year

Private Duty Nursing:

  • Coverage with limitations (refer to plan document for details)

Hearing Aids:

  • Under age 18: 1 aid per ear every 24 months
  • Age 18 and over: $2,500 per aid per ear every 24 months

Cost Examples

These examples show how this plan might cover costs for sample 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

9 months of in-network prenatal care and hospital delivery

Services Include:

  • 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: $3,500
  • Copayments: $0
  • Coinsurance: $1,300
  • What isn't covered (limits/exclusions): $60
  • Total: $4,860

Plan Assumptions:

  • Overall deductible: $3,500
  • Specialist coinsurance: 20%
  • Hospital facility coinsurance: 20%
  • Other coinsurance: 20%

Example 2: Mia's Simple Fracture

In-network emergency room visit and follow-up care

Services Include:

  • 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: $2,400
  • Copayments: $0
  • Coinsurance: $0
  • What isn't covered (limits/exclusions): $400
  • Total: $2,800

Plan Assumptions:

  • Overall deductible: $3,500
  • Specialist coinsurance: 20%
  • Hospital facility coinsurance: 20%
  • Other coinsurance: 20%

Example 3: Managing Joe's Type 2 Diabetes

A year of routine in-network care of a well-controlled condition

Services Include:

  • 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: $3,500
  • Copayments: $0
  • Coinsurance: $200
  • What isn't covered (limits/exclusions): $20
  • Total: $3,720

Plan Assumptions:

  • Overall deductible: $3,500
  • Specialist coinsurance: 20%
  • Hospital facility coinsurance: 20%
  • Other: No charge

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

Important Rights & 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.

Rights to Continue Coverage

If you want to continue your coverage after it ends, agencies can help:

  • Department of Labor's Employee Benefits Security Administration

    • Phone: 1-866-444-EBSA (3272)
    • Website: www.dol.gov/ebsa/healthreform

  • 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 for that medical claim
  • Your plan documents provide complete information on how to submit a claim, appeal, or grievance
  • Contact the plan: 1-888-832-0354
  • U.S. Department of Labor's Employee Benefits Security Administration:
    • Phone: 1-866-444-EBSA (3272)
    • Website: 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 (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

Additional Resources

Important Contacts

  • Customer Service: 1-888-832-0354
  • Provider Search: provider-search.kariashealth.com
  • Karias Care Concierge: 1-888-832-0354
  • Prescription Drug Information: hpiTPA.com
  • Complete Terms of Coverage: Call 1-888-832-0354 for a copy
  • Glossary of Terms: healthcare.gov/sbc-glossary or call 1-888-832-0354

Understanding Key Terms

For definitions of common terms used in this document, 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 of the Glossary.

Support Team Notes

Document Version: v1.0
Document Pages: 5 pages total
Effective Date: January 1, 2026 – December 31, 2026
Last Updated: Document version 1.0

Key Points for Customer Support:

  1. Always verify if services require preauthorization before approval
  2. Remind customers that in-network providers offer the best value
  3. Preventive care is covered at no charge in-network with deductible waived
  4. Insulin cost is capped at $100 per 30-day supply
  5. All costs shown are AFTER deductible is met unless otherwise specified
  6. Premium information is provided separately and not included in this document
  7. Coverage examples are illustrative only and actual costs will vary