Mascorp Gold Plan - Summary of Benefits and Coverage (2026)
This Summary of Benefits and Coverage (SBC) outlines the Mascorp Management Corporation Gold Plan (EPO) for employees and dependents, effective January 1, 2026 through December 31, 2026. The plan operates as an Exclusive Provider Organization (EPO), meaning members must use in-network providers for coverage. This comprehensive guide details deductibles, copayments, out-of-pocket limits, covered services, and specific cost-sharing requirements to help members understand their healthcare coverage and financial responsibilities.
Plan Overview
Plan Name: Mascorp Management Corporation Gold Plan
Plan Type: EPO (Exclusive Provider Organization)
Coverage: Employee & Dependents
Coverage Period: January 1, 2026 – December 31, 2026
Plan Version: v1.0
Key Contact Information:
- Phone: 1-888-832-0354
- Provider Search: provider-search.kariashealth.com
- Karias Care Concierge: 1-888-832-0354
- Prescription Information: hpiTPA.com
Critical Plan Features at a Glance
Deductibles
- Single Plan: $500 per employee
- Family Plan: $500 per person / $1,000 family aggregate
How It Works:
- Each family member must meet their individual $500 deductible
- Once the family collectively pays $1,000, the family deductible is met
- Some services are covered BEFORE meeting the deductible (see below)
Services Covered Before Deductible
✅ YES - The following are covered before meeting your deductible:
- In-network preventive services
- Physician office visits (primary care and specialist)
- Urgent care visits
- Diagnostic tests
- Imaging services
- Prescription drugs
- Mental health outpatient office visits
Out-of-Pocket Limits
- Single Plan: $7,000 per employee (maximum annual cost)
- Family Plan: $7,000 per person / $14,000 family aggregate
What This Means: This is the absolute maximum you'll pay in a year for covered services. Once reached, the plan pays 100% of covered services for the rest of the year.
What Does NOT Count Toward Out-of-Pocket Limit
❌ Preauthorization penalties
❌ Monthly premiums
❌ Balance billing charges
❌ Services the plan doesn't cover
Network Requirements
⚠️ IMPORTANT: This is an EPO plan
- You MUST use in-network providers for coverage
- Out-of-network services are NOT COVERED (except emergency care)
- No referrals needed to see specialists
- Always verify provider is in-network before receiving services
- Search providers at: provider-search.kariashealth.com
Detailed Cost Breakdown by Service
Office Visits & Preventive Care
| Service | In-Network Cost | Out-of-Network | Notes |
|---|---|---|---|
| Primary Care Visit | $25 copay/visit (deductible waived) | Not covered | For injury or illness treatment |
| Specialist Visit | $40 copay/visit (deductible waived) | Not covered | No referral required |
| Preventive Care/Screening/Immunization | No charge (deductible waived) | Not covered | Ask provider if service is preventive |
| Urgent Care | $25 copay/visit (deductible waived) | $25 copay/visit | Covered in and out of network |
Important: You may have to pay for services that aren't considered preventive. Always ask your provider if the services they're recommending are preventive, then verify what your plan will pay.
Diagnostic Services & Testing
| Service | In-Network Cost | Out-of-Network | Notes |
|---|---|---|---|
| Diagnostic Tests (x-ray, blood work) | $25 copay/visit | Not covered | No limitations |
| Imaging (CT/PET scans, MRIs) | $25 copay/visit | Not covered | No limitations |
Prescription Drug Coverage
Deductible: Waived for all prescription drugs
More Information: hpiTPA.com
Retail Pharmacy (30-day supply)
| Drug Tier | Copay | Out-of-Network |
|---|---|---|
| Generic | $20 | Not covered |
| Preferred Brand | $35 | Not covered |
| Non-Preferred Brand | $60 | Not covered |
Retail 90-Day Supply / Mail Order (90-day supply)*
| Drug Tier | Copay | Out-of-Network |
|---|---|---|
| Generic | $40 | Not covered |
| Preferred Brand | $70 | Not covered |
| Non-Preferred Brand | $180 | Not covered |
*Maintenance drugs only
Specialty Drugs (30-day supply only)
| Drug Tier | Cost | Maximum | Out-of-Network |
|---|---|---|---|
| Generic Specialty | 10% coinsurance | $200 max | Not covered |
| Preferred Specialty | 20% coinsurance | $250 max | Not covered |
| Non-Preferred Specialty | 20% coinsurance | $350 max | Not covered |
⚠️ Important Prescription Drug Notes:
- Certain prescription drugs are subject to Step Therapy (you may need to try one drug before another is covered)
- Refer to plan document for specialty drug coverage requirements and limitations
- 90-day supplies for maintenance medications only
Emergency & Urgent Care
| Service | In-Network Cost | Out-of-Network | Notes |
|---|---|---|---|
| Emergency Room Care | $250 copay/visit (after deductible) | $250 copay/visit (after deductible) | Copay waived if admitted to hospital |
| Emergency Medical Transportation | Deductible only | Deductible only | Ambulance services |
| Urgent Care | $25 copay/visit (deductible waived) | $25 copay/visit (deductible waived) | Covered anywhere |
Hospital & Surgical Services
| Service | In-Network Cost | Out-of-Network | Notes |
|---|---|---|---|
| Outpatient Surgery - Facility Fee | $250 copay/visit | Not covered | Preauth required for joint replacement & non-emergent spine surgeries |
| Outpatient Surgery - Physician/Surgeon Fees | Deductible only | Not covered | |
| Hospital Stay - Facility Fee | Deductible only | Not covered | Preauth required or pay $250 penalty |
| Hospital Stay - Physician/Surgeon Fees | Deductible only | Not covered |
⚠️ Preauthorization Critical: Failure to obtain preauthorization for hospital stays results in a $250 penalty charge.
Mental Health & Substance Abuse Services
Outpatient Services
| Service | In-Network Cost | Out-of-Network | Notes |
|---|---|---|---|
| Office Visit | $25 copay/visit (deductible waived) | Not covered | |
| Intensive Outpatient Treatment | No charge (deductible waived) | Not covered | Preauthorization required |
Inpatient Services
| Service | In-Network Cost | Out-of-Network | Notes |
|---|---|---|---|
| Inpatient Mental Health/Substance Abuse | Deductible only | Not covered | Preauth required or pay $250 penalty |
Maternity & Pregnancy Services
| Service | In-Network Cost | Out-of-Network | Notes |
|---|---|---|---|
| Office Visits | No charge (deductible waived) | Not covered | Prenatal care |
| Childbirth/Delivery Professional Services | No charge (deductible waived) | Not covered | Physician/midwife fees |
| Childbirth/Delivery Facility Services | Deductible only | Not covered | Hospital room & board |
⚠️ Important Maternity Notes:
- Maternity care may include tests and services described elsewhere in this document
- Preauthorization required for hospital stays over:
- 48 hours for normal delivery
- 96 hours for caesarean delivery
- Failure to obtain preauth results in $250 penalty
Rehabilitation & Recovery Services
Home Health Care
- Cost: No charge (deductible waived)
- Coverage: Not covered out-of-network
- Limit: 30 visits per year
- ⚠️ Preauthorization required
Rehabilitation Services
| Service Type | In-Network Cost | Out-of-Network | Notes |
|---|---|---|---|
| Inpatient Rehabilitation | Deductible only | Not covered | 60 days/year limit; Preauth required or $250 penalty |
| Outpatient Rehabilitation | $40 copay/visit (deductible waived) | Not covered | See visit limits below |
Outpatient Therapy Visit Limits:
- Physical & Occupational Therapy: 100 visits/year combined
- Speech Therapy: 30 visits/year
- ⚠️ Preauthorization required for Occupational & Speech therapy
Habilitation Services (Developmental)
| Service Type | In-Network Cost | Out-of-Network | Notes |
|---|---|---|---|
| Early Intervention | $40 copay/visit | Not covered | Coverage to age 3 |
| Developmental Delay | $40 copay/visit | Not covered | Preauth & visit limits based on services |
Skilled Nursing Care
- Cost: Deductible only
- Coverage: Not covered out-of-network
- Limit: 100 days per year
- ⚠️ Preauthorization required or pay $250 penalty
Durable Medical Equipment (DME)
- Cost: Deductible only
- Coverage: Not covered out-of-network
- ⚠️ Preauthorization required for:
- Equipment rental over 3 months
- Equipment costing over $1,000
- Implantable loop recorders
- Defibrillators
Hospice Services
- Cost: No charge (deductible waived)
- Coverage: Not covered out-of-network
- ⚠️ Preauthorization required
Children's Vision & Dental
| Service | In-Network Cost | Out-of-Network | Notes |
|---|---|---|---|
| Children's Eye Exam | No charge (deductible waived) | Not covered | 1 exam per 12 months |
| Children's Glasses | Not covered | Not covered | Not a covered benefit |
| Children's Dental Check-up | Not covered | Not covered | Not a covered benefit |
Services NOT Covered by This Plan
The following services are excluded and not covered under this plan:
❌ Acupuncture
❌ Dental care (routine adult & child)
❌ Private duty nursing
❌ Bariatric surgery (weight loss surgery)
❌ Long-term care
❌ Routine foot care
❌ Cosmetic surgery
❌ Non-emergency care when traveling outside the U.S.
❌ Children's glasses
❌ Children's dental check-ups
Note: This is not a complete list. Check your plan document for additional exclusions.
Other Covered Services (With Limitations)
The following services ARE covered, but with specific limitations:
✅ Chiropractic Care
- Limit: 30 visits per year
✅ Routine Eye Care (Adults)
- Limit: 1 exam per 12 months
✅ Hearing Aids
- Limit: 1 per ear every 36 months (for members up to age 21)
✅ Weight Loss Programs
- Limit: $150 per person per year, up to $300 per family per year
✅ Infertility Treatment
- Coverage available (check plan document for specific limitations)
Preauthorization Requirements Summary
⚠️ CRITICAL: Failure to obtain required preauthorization results in a $250 penalty charge
Services Requiring Preauthorization:
| Service Category | Specific Requirements |
|---|---|
| Surgical Services | • Total joint replacement<br>• Non-emergent spine surgeries |
| Hospital Stays | • All inpatient admissions<br>• Maternity stays over 48 hrs (normal) or 96 hrs (c-section) |
| Mental Health | • Intensive outpatient treatment<br>• Inpatient mental health/substance abuse |
| Rehabilitation | • Inpatient rehabilitation<br>• Occupational therapy (outpatient)<br>• Speech therapy (outpatient) |
| Home & Specialized Care | • Home health care<br>• Skilled nursing care<br>• Hospice services |
| Equipment | • DME rental over 3 months<br>• DME over $1,000<br>• Implantable loop recorders & defibrillators |
| Developmental Services | • Habilitation services (visit limits apply) |
How to Obtain Preauthorization: Call 1-888-832-0354 before receiving the service
Coverage Examples
The plan provides three real-world examples of how coverage works:
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 Out-of-Pocket Costs:
- Deductibles: $500
- Copayments: $200
- Coinsurance: $0
- Limits/Exclusions: $60
- Total Peg Pays: $760
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 Out-of-Pocket Costs:
- Deductibles: $500
- Copayments: $600
- Coinsurance: $0
- Limits/Exclusions: $0
- Total Mia Pays: $1,100
Example 3: Managing Joe's Type 2 Diabetes
Scenario: A year of routine in-network care for 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 Out-of-Pocket Costs:
- Deductibles: $500
- Copayments: $700
- Coinsurance: $0
- Limits/Exclusions: $20
- Total Joe Pays: $1,220
Important Plan Compliance Information
Minimum Essential Coverage
✅ YES - This plan provides Minimum Essential Coverage as defined by the Affordable Care Act.
Minimum Value Standards
✅ YES - This plan meets Minimum Value Standards.
Member Rights & Resources
Right to Continue Coverage
If your coverage ends, you have rights to continue coverage. Contact:
- Department of Labor's Employee Benefits Security Administration
- Phone: 1-866-444-EBSA (3272)
- Website: www.dol.gov/ebsa/healthreform
Alternative Options:
- Individual insurance through the Health Insurance Marketplace
- Visit: www.HealthCare.gov
- Call: 1-800-318-2596
Grievance and Appeals Rights
If your claim is denied or you have a complaint:
Contact the Plan:
- Phone: 1-888-832-0354
- Review your Explanation of Benefits (EOB)
- Consult your plan documents for complete grievance procedures
Federal Assistance:
- 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
Glossary & Additional Resources
Key Terms to Know
Deductible: The amount you must pay before the plan starts paying for covered services.
Copayment (Copay): A fixed dollar amount you pay for a covered service.
Coinsurance: Your share of costs for a covered service, calculated as a percentage.
Out-of-Pocket Limit: The maximum amount you'll pay in a year for covered services.
EPO (Exclusive Provider Organization): You must use in-network providers for coverage (except emergencies).
Preauthorization: Approval required before receiving certain services to ensure coverage.
Balance Billing: When an out-of-network provider bills you for the difference between their charge and what your plan pays.
Complete Glossary
For definitions of all underlined terms in this document:
- Visit: healthcare.gov/sbc-glossary
- Call: 1-888-832-0354 to request a printed copy
Complete Plan Documents
For full terms and conditions of coverage:
- Call: 1-888-832-0354
- This SBC is only a summary; complete terms are in your plan documents
Preventive Care Details
For a complete list of covered preventive services:
- Visit: healthcare.gov/coverage/preventive-care-benefits
Quick Reference Contact Information
| Need | Contact | Details |
|---|---|---|
| General Questions | 1-888-832-0354 | Karias Care Concierge |
| Find a Provider | provider-search.kariashealth.com | Online provider directory |
| Prescription Drug Info | hpiTPA.com | Pharmacy benefit details |
| Preauthorization | 1-888-832-0354 | Call before receiving service |
| Claims/Appeals | 1-888-832-0354 | Grievance assistance |
| Federal Assistance | 1-866-444-EBSA (3272) | Dept. of Labor |
Support Team Quick Tips
Most Common Member Questions:
-
"Do I need a referral to see a specialist?"
- NO - Members can see any in-network specialist without a referral
-
"Is out-of-network covered?"
- NO - This is an EPO plan. Out-of-network is NOT covered except for emergency care
-
"What's covered before I meet my deductible?"
- Preventive care, office visits (PCP & specialist), urgent care, diagnostic tests, imaging, prescriptions, and mental health outpatient visits
-
"Do I need preauthorization?"
- Check the preauthorization table. Common: hospital stays, surgeries, inpatient care, certain therapies, DME over $1,000
-
"What happens if I don't get preauthorization?"
- $250 penalty charge in addition to regular cost-sharing
-
"What's my maximum out-of-pocket?"
- Single: $7,000 | Family: $14,000
Document Version: v1.0
Last Updated: Effective January 1, 2026
Document Source: 006D2513_D2513U6&4M001_SBC_Eff 01012026_v1.0_Gold Plan-Draft.pdf
⚠️ Important: This is a knowledge base summary. For legally binding terms and complete coverage details, always refer to the official plan documents. Call 1-888-832-0354 for questions.