Bronze HSA Plan - Summary of Benefits and Coverage

Plan Overview

Plan Name: Bronze HSA Plan
Provider: Mascorp Management Corporation
Coverage Period: January 1, 2026 – December 31, 2026
Coverage For: Employee & Dependents
Plan Type: QHDHP EPO (Qualified High Deductible Health Plan - Exclusive Provider Organization)
Contact Number: 1-888-832-0354
Provider Search: provider-search.kariashealth.com
Care Concierge: Karias Care Concierge at 1-888-832-0354
Prescription Information: hpiTPA.com

Key Plan Features

Overall Deductibles

Single Plan: $3,000 (employee only)
Family Plan: $6,000 (employee & family combined)

Important: You must pay all costs from providers up to the deductible amount before the plan begins to pay. For family plans, the overall family deductible must be met before the plan begins to pay.

Out-of-Pocket Limits

Single Plan: $6,000 (employee)
Family Plan: $6,000 per person / $10,000 family maximum

Important: This 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 limit is met.

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

Preauthorization penalties
Premiums
Balance billing charges
Health care services not covered by the plan

Services Covered Before Deductible

Yes - In-network preventive services are covered before you meet your deductible at no charge.

Specific Service Deductibles

No - You don't have to meet separate deductibles for specific services.

Network Requirements

Yes - You pay less when using network providers. Out-of-network services are generally not covered except for emergency care and urgent care (at in-network level).

Warning: Network providers might use out-of-network providers for some services (such as lab work). Always check with your provider before getting services to avoid unexpected costs.

Specialist Referrals

No - You may see a specialist of your choice without a referral.

Detailed Coverage Information

Primary Care & Specialist Visits

Primary Care Visit (Injury or Illness)

In-Network: Deductible only (pay full cost until deductible met)
Out-of-Network: Not covered
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: Not covered

Preventive Care/Screening/Immunization

In-Network: No charge; deductible waived
Out-of-Network: Not covered
Notes: For a list of covered preventive services, visit healthcare.gov/coverage/preventive-care-benefits

Diagnostic Testing & Imaging

Diagnostic Tests (X-ray, Blood Work)

In-Network: Deductible only
Out-of-Network: Not covered

Imaging (CT/PET Scans, MRIs)

In-Network: Deductible only
Out-of-Network: Not covered

Prescription Drug Coverage

Important Notes:

Deductible applies except to preventive care drugs
Certain prescription drugs are subject to Step Therapy (you may be required to use a different prescription drug first)
Refer to plan document for coverage requirements and other limitations related to specialty drugs
*Maintenance drugs only for 90-day supplies

Generic Drugs

Retail (30 days): $5 copay per prescription
Retail (90 days): $10 copay per prescription*
Mail Order (90 days): $10 copay per prescription*
Out-of-Network: Not covered

Preferred Brand Drugs

Retail (30 days): $20 copay per prescription
Retail (90 days): $40 copay per prescription*
Mail Order (90 days): $40 copay per prescription*
Out-of-Network: Not covered

Non-Preferred Brand Drugs

Retail (30 days): $35 copay per prescription
Retail (90 days): $70 copay per prescription*
Mail Order (90 days): $70 copay per prescription*
Out-of-Network: Not covered

Specialty Drugs

Retail (30 days): 10% coinsurance (maximum $200)
Out-of-Network: Not covered

Outpatient Surgery

Facility Fee (Ambulatory Surgery Center)

In-Network: Deductible only
Out-of-Network: Not covered
Preauthorization Required: Total joint replacement and non-emergent spine surgeries

Physician/Surgeon Fees

In-Network: Deductible only
Out-of-Network: Not covered

Emergency & Urgent Care

Emergency Room Care

In-Network: 100% after in-network deductible
Out-of-Network: 100% after in-network deductible
Notes: No limitations

Emergency Medical Transportation

In-Network: 100% after in-network deductible
Out-of-Network: 100% after in-network deductible
Notes: No limitations

Urgent Care

In-Network: Deductible only
Out-of-Network: Covered at in-network level, subject to allowed amount
Notes: No limitations

Hospital Stays

Facility Fee (Hospital Room)

In-Network: Deductible only
Out-of-Network: Not covered
Preauthorization Required: Must preauthorize or you pay $250 more

Physician/Surgeon Fees

In-Network: Deductible only
Out-of-Network: Not covered

Mental Health, Behavioral Health & Substance Abuse Services

Outpatient Services

In-Network: Deductible only
Out-of-Network: Not covered
Preauthorization Required: Intensive outpatient treatment

Inpatient Services

In-Network: Deductible only
Out-of-Network: Not covered
Preauthorization Required: Must preauthorize or you pay $250 more

Maternity Care

Prenatal Care Office Visits

In-Network: No charge; deductible waived
Out-of-Network: Not covered

Postnatal Care Office Visits

In-Network: Deductible only
Out-of-Network: Not covered

Childbirth/Delivery Professional Services

In-Network: Deductible only
Out-of-Network: Not covered

Childbirth/Delivery Facility Services

In-Network: Deductible only
Out-of-Network: Not covered

Important Notes:

Maternity care may include tests and services described elsewhere in the SBC
Preauthorization required for stays over 48 hours (normal delivery) or 96 hours (caesarean) or you pay $250 more

Rehabilitation & Special Health Needs

Home Health Care

In-Network: Deductible only
Out-of-Network: Not covered
Limits: 30 visits per year
Preauthorization Required: Yes

Rehabilitation Services - Inpatient

In-Network: Deductible only
Out-of-Network: Not covered
Limits: 60 days per year
Preauthorization Required: Yes (or you pay $250 more)

Rehabilitation Services - Outpatient

In-Network: Deductible only
Out-of-Network: Not covered
Limits: 100 visits per year combined for Occupational and Physical therapies; 30 visits per year for Speech therapy
Preauthorization Required: Yes for Occupational & Speech therapy

Habilitation Services - Early Intervention

In-Network: Deductible only
Out-of-Network: Not covered
Limits: To age 3
Notes: Preauthorization and visit limits based on services provided

Habilitation Services - Developmental Delay

In-Network: Deductible only
Out-of-Network: Not covered
Notes: Preauthorization and visit limits based on services provided

Skilled Nursing Care

In-Network: Deductible only
Out-of-Network: Not covered
Limits: 100 days per year
Preauthorization Required: Yes (or you pay $250 more)

Durable Medical Equipment

In-Network: Deductible only
Out-of-Network: Not covered
Preauthorization Required: For rental over 3 months, equipment over $1,000, implantable loop recorders & defibrillators

Hospice Services

In-Network: Deductible only
Out-of-Network: Not covered
Preauthorization Required: Yes

Children's Vision & Dental

Children's Eye Exam

In-Network: Deductible only
Out-of-Network: Not covered
Limits: 1 exam per 12 months

Children's Glasses

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

Children's Dental Check-up

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

Excluded Services

Services NOT Covered by This Plan

(Check your policy or plan document for complete list)

Acupuncture
Dental care (routine adult & child)
Private duty nursing
Bariatric surgery
Long term care
Routine foot care
Cosmetic surgery
Non-emergency care when traveling outside U.S.

Other Covered Services

Additional Services with Limitations

(This isn't a complete list - see plan document)

Chiropractic Care

Limit: 30 visits per year

Routine Eye Care (Adult)

Limit: 1 exam per 12 months

Hearing Aids

Limit: 1 per aid per ear per 36 months (to age 21)

Weight Loss Programs

Limit: $150 per person per year, up to $300 per family per year

Infertility Treatment

Coverage: Yes (limitations may apply)

Coverage Examples

These examples show how the 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

Scenario: 9 months of in-network prenatal care and hospital delivery
Total Example Cost: $12,700

Services Include:

Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)

Peg Would Pay:

Deductibles: $3,000
Copayments: $10
Coinsurance: $0
Limits/Exclusions: $60
Total: $3,070

Plan Coverage Notes:

Plan's overall deductible: $3,000
Specialist coinsurance
Hospital (facility) coinsurance
Other coinsurance

Example 2: Mia's Simple Fracture

Scenario: In-network emergency room visit and follow-up care
Total Example Cost: $2,800

Services Include:

Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)

Mia Would Pay:

Deductibles: $2,400
Copayments: $0
Coinsurance: $0
Limits/Exclusions: $0
Total: $2,400

Plan Coverage Notes:

Plan's overall deductible: $3,000
Specialist coinsurance
Hospital (facility) coinsurance
Other coinsurance

Example 3: Managing Joe's Type 2 Diabetes

Scenario: A year of routine in-network care of a well-controlled condition
Total Example Cost: $5,600

Services Include:

Primary care physician office visits (including disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)

Joe Would Pay:

Deductibles: $3,000
Copayments: $90
Coinsurance: $0
Limits/Exclusions: $20
Total: $3,110

Plan Coverage Notes:

Plan's overall deductible: $3,000
Specialist coinsurance
Hospital (facility) coinsurance
Other: no charge

Important: These coverage examples are based on self-only coverage. Focus on the cost-sharing amounts (deductibles, copayments, and coinsurance) and excluded services when comparing plans.

Important Plan Information

Minimum Essential Coverage

Yes - This plan provides Minimum Essential Coverage, which generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage.

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

Minimum Value Standards

Yes - This plan meets Minimum Value Standards.

Note: 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 & Appeals

Right 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

Other Options: 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 Information:

Plan: 1-888-832-0354
U.S. Department of Labor's Employee Benefits Security Administration: 1-866-444-EBSA (3272)
Website: www.dol.gov/ebsa/healthreform

Where to Find Information:

Explanation of benefits for medical claims
Complete plan documents for submission procedures

Language Access Services

Available 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

Important Definitions & Glossary

For general definitions of common terms such as:

Allowed amount
Balance billing
Coinsurance
Copayment
Deductible
Provider
Other underlined terms

View the Glossary:

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

Quick Reference Contact Information

Purpose	Contact
General Plan Questions	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	1-888-832-0354
Grievances & Appeals	1-888-832-0354
Department of Labor EBSA	1-866-444-EBSA (3272)
Health Insurance Marketplace	1-800-318-2596

Support Team Quick Tips

Key Points to Emphasize:

Preventive care is FREE when using in-network providers (no deductible)
Always verify network status before receiving services
Preauthorization is crucial - missing it costs customers $250 extra
Out-of-network care is NOT covered except emergencies and urgent care
Step Therapy may apply to prescription drugs

Common Customer Scenarios:

Emergency situations: Covered at in-network level regardless of provider
Urgent care: Can use out-of-network but will be reimbursed at in-network level
Surgery: Must preauthorize or face $250 penalty
Hospital stays: Must preauthorize or face $250 penalty
Maternity: Prenatal visits are FREE; delivery requires preauthorization for extended stays

Document Version

Version: v1.0
Effective Date: January 1, 2026
Document Pages: 5 of 5