Silver Plan - Summary of Benefits and Coverage (SBC)
This Summary of Benefits and Coverage (SBC) document outlines the Silver Plan health insurance coverage offered by Mascorp Management Corporation. It details cost-sharing arrangements including deductibles, copayments, and coinsurance for various medical services. The plan operates as an EPO, requiring members to use in-network providers (out-of-network services are not covered except for emergencies). Key features include a $1,500 individual deductible, $7,000 individual out-of-pocket maximum, and coverage for preventive services and office visits before meeting the deductible.
Coverage Period: January 1, 2026 – December 31, 2026
Plan Provider: Mascorp Management Corporation
Plan Type: EPO (Exclusive Provider Organization)
Coverage: Employee & Dependents
Version: 1.0
Contact Information
- Customer Service: 1-888-832-0354
- Provider Search: provider-search.kariashealth.com
- Karias Care Concierge: 1-888-832-0354
- Prescription Drug Information: hpiTPA.com
- Glossary Reference: healthcare.gov/sbc-glossary
- Preventive Care Services List: healthcare.gov/coverage/preventive-care-benefits
Plan Overview & Key Features
Overall Deductibles
Single Plan:
- Employee deductible: $1,500
Family Plan:
- Individual deductible: $1,500 per person
- Family deductible: $3,000 total
Important: Each family member must meet their own individual deductible until the total deductible expenses paid by all family members meets the overall family deductible of $3,000.
Out-of-Pocket Limits
Single Plan:
- Employee maximum: $7,000
Family Plan:
- Individual maximum: $7,000 per person
- Family maximum: $14,000 total
What's NOT included in out-of-pocket limits:
- Preauthorization penalties
- Premiums
- Balance billing charges
- Health care services not covered by the plan
Services Covered Before Deductible
Yes, the following services are covered before you meet your deductible:
- In-network preventive services
- Physician office visits (primary care and specialist)
- Urgent care visits
- Mental health outpatient office visits
- Intensive outpatient treatment
Network Requirements
Do you need to use network providers? Yes. This is an EPO plan, which means:
- You pay the least when using in-network providers
- Out-of-network services are NOT covered (except emergency care)
- You may receive balance bills from out-of-network providers
- Network providers might use out-of-network providers for some services (like lab work) - always check before receiving services
Do you need referrals to see specialists? No. You can see any in-network specialist without a referral.
Detailed Cost-Sharing by Service Category
Office & Clinic Visits
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Primary Care Visit (injury/illness) | $25 copay per visit (deductible waived) | Not covered | May have to pay for non-preventive services |
| Specialist Visit | $40 copay per visit (deductible waived) | Not covered | Ask provider if services are preventive |
| Preventive Care/Screening/Immunization | No charge (deductible waived) | Not covered | Check healthcare.gov for covered preventive services list |
Diagnostic Tests & Imaging
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Diagnostic Tests (x-ray, blood work) | $25 copay per visit | Not covered | None |
| Imaging (CT/PET scans, MRIs) | $25 copay per visit | Not covered | None |
Prescription Drug Coverage
Note: More information available at hpiTPA.com
Deductible: Waived for all prescription drugs
Important: Certain prescription drugs are subject to Step Therapy - you may be required to use a different prescription drug first.
Generic Drugs
- Retail (30 days): $20 copay per prescription
- Retail (90 days): $40 copay per prescription
- Mail Order (90 days): $40 copay per prescription (*maintenance drugs only)
- Out-of-Network: Not covered
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 (*maintenance drugs only)
- Out-of-Network: Not covered
Non-Preferred Brand Drugs
- Retail (30 days): $60 copay per prescription
- Retail (90 days): $180 copay per prescription
- Mail Order (90 days): $180 copay per prescription (*maintenance drugs only)
- Out-of-Network: Not covered
Specialty Drugs (Retail 30 days only)
- Generic: 10% coinsurance (Maximum $200)
- Preferred: 20% coinsurance (Maximum $250)
- Non-Preferred: 20% coinsurance (Maximum $350)
- Out-of-Network: Not covered
Important Notes:
- Refer to plan document for coverage requirements and other limitations related to specialty drugs
- Step Therapy may apply to certain medications
Outpatient Surgery
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Facility Fee (ambulatory surgery center) | $250 copay per visit | Not covered | Preauthorization required for total joint replacement and non-emergent spine surgeries |
| Physician/Surgeon Fees | Deductible only | Not covered | None |
Emergency & Urgent Care
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Emergency Room Care | $250 copay per visit after in-network deductible | $250 copay per visit after in-network deductible | Copay waived if admitted to hospital |
| Emergency Medical Transportation | In-network deductible only | In-network deductible only | None |
| Urgent Care | $25 copay per visit (deductible waived) | $25 copay per visit (deductible waived) | None |
Hospital Stays
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Facility Fee (hospital room) | Deductible only | Not covered | Preauthorization required or you pay $250 more |
| Physician/Surgeon Fees | Deductible only | Not covered | None |
Mental Health, Behavioral Health & Substance Abuse Services
Outpatient Services
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Office Visit | $25 copay per visit (deductible waived) | Not covered | None |
| Intensive Outpatient Treatment | No charge (deductible waived) | Not covered | Preauthorization required |
Inpatient Services
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Inpatient Services | Deductible only | Not covered | Preauthorization required or you pay $250 more |
Maternity & Pregnancy Care
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Office Visits | No charge (deductible waived) | Not covered | Maternity care may include tests & services described elsewhere in SBC |
| Childbirth/Delivery Professional Services | No charge (deductible waived) | Not covered | Requires preauthorization for stays over 48 hours (normal delivery) or 96 hours (caesarean) or you pay $250 more |
| Childbirth/Delivery Facility Services | Deductible only | Not covered | Same preauthorization requirements as above |
Recovery & Special Health Needs
Home Health Care
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Home Health Care | No charge (deductible waived) | Not covered | Preauthorization required. Limited to 30 visits per year |
Rehabilitation Services
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Inpatient Rehabilitation | Deductible only | Not covered | Limited to 60 days per year. Preauthorization required or you pay $250 more |
| Outpatient Rehabilitation | $40 copay per visit (deductible waived) | Not covered | Preauthorization required for Occupational & Speech therapy. 100 visits per year combined for Occupational and Physical therapies. 30 visits per year for Speech therapy |
Habilitation Services
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Early Intervention | $40 copay per visit | Not covered | Available to age 3 |
| Developmental Delay | $40 copay per visit | Not covered | Preauthorization and visit limits based on services provided |
Skilled Nursing Care
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Skilled Nursing Care | Deductible only | Not covered | Limited to 100 days per year. Preauthorization required or you pay $250 more |
Durable Medical Equipment (DME)
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| DME | Deductible only | Not covered | Preauthorization required for: rental over 3 months, equipment over $1,000, implantable loop recorders & defibrillators |
Hospice Services
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Hospice Services | No charge (deductible waived) | Not covered | Preauthorization required |
Children's Vision & Dental Care
| Service | In-Network Cost | Out-of-Network | Additional Information |
|---|---|---|---|
| Children's Eye Exam | No charge (deductible waived) | Not covered | Limited to 1 exam per 12 months |
| 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 (routine adult & child)
- Private duty nursing
- Bariatric surgery
- Long-term care
- Routine foot care
- Cosmetic surgery
- Non-emergency care when traveling outside the U.S.
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 (limitations may apply):
- Chiropractic Care: Limited to 30 visits per year
- Routine Eye Care (Adult): 1 exam per 12 months
- Hearing Aids: 1 per aid per ear every 36 months (to age 21)
- Weight Loss Programs: $150 per person per year, up to $300 per family per year
- Infertility Treatment: Covered (check plan document for limitations)
Note: This is not a complete list. Please see your plan document for full details.
Coverage Examples
The following examples show how this plan might cover costs in specific medical situations. These are estimates only - your actual costs will differ based on actual care received and provider charges.
Example 1: Peg is Having a Baby
9 months of in-network prenatal care and hospital delivery
Total Example Cost: $12,700
Peg's Cost Breakdown:
- Deductibles: $1,500
- Copayments: $10
- Coinsurance: $0
- Limits/Exclusions: $60
- Total Peg Pays: $1,570
Services included: Specialist office visits (prenatal care), childbirth/delivery professional services, childbirth/delivery facility services, diagnostic tests (ultrasounds and blood work), specialist visit (anesthesia)
Plan Details Used:
- Overall deductible: $1,500
- Specialist copayment: $40
- Hospital facility: Deductible only
- Other copayment: $25
Example 2: Mia's Simple Fracture
In-network emergency room visit and follow-up care
Total Example Cost: $2,800
Mia's Cost Breakdown:
- Deductibles: $1,500
- Copayments: $300
- Coinsurance: $0
- Limits/Exclusions: $0
- Total Mia Pays: $1,800
Services included: Emergency room care (including medical supplies), diagnostic test (x-ray), durable medical equipment (crutches), rehabilitation services (physical therapy)
Plan Details Used:
- Overall deductible: $1,500
- Specialist copayment: $40
- Hospital facility: Deductible only
- Other copayment: $40
Example 3: Managing Joe's Type 2 Diabetes
A year of routine in-network care of a well-controlled condition
Total Example Cost: $5,600
Joe's Cost Breakdown:
- Deductibles: $900
- Copayments: $700
- Coinsurance: $0
- Limits/Exclusions: $20
- Total Joe Pays: $1,620
Services included: Primary care physician office visits (including disease education), diagnostic tests (blood work), prescription drugs, durable medical equipment (glucose meter)
Plan Details Used:
- Overall deductible: $1,500
- Specialist copayment: $40
- Hospital facility: Deductible only
- Other deductible: Applies to specific services
Important Coverage 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
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
Other Options: You may be able to buy 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
- Check your plan documents for complete information on submitting claims, appeals, or grievances
- Contact the plan at: 1-888-832-0354
- You may also contact:
- 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 (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 Notes for Support Team
Key Points to Remember:
- This is an EPO plan - Out-of-network care is NOT covered except for emergency services
- Preauthorization is critical - Failure to get preauthorization results in $250 additional cost for many services
- Deductible is waived for many common services including office visits, preventive care, and prescriptions
- Step Therapy may apply to prescription drugs - patients may need to try one medication before another is covered
- Annual limits apply to many services - always check visit/day limits before confirming coverage
- Balance billing is possible - patients may receive bills from out-of-network providers even if a network provider uses them for services like lab work
Services Requiring Preauthorization:
- Total joint replacement surgery (outpatient)
- Non-emergent spine surgeries (outpatient)
- Hospital stays (or pay $250 more)
- Intensive outpatient mental health treatment
- Maternity stays over 48 hours (normal) or 96 hours (caesarean) - or pay $250 more
- Home health care
- Inpatient rehabilitation (or pay $250 more)
- Occupational therapy
- Speech therapy
- Skilled nursing care (or pay $250 more)
- DME rental over 3 months, equipment over $1,000, implantable loop recorders & defibrillators
- Hospice services
- Habilitation services (visit limits based on services)
Common Customer Questions:
Q: What's the difference between deductible, copayment, and coinsurance?
- Deductible: Amount you pay before the plan starts paying
- Copayment: Fixed dollar amount you pay per service
- Coinsurance: Percentage of costs you pay after meeting deductible
Q: Can I see any doctor?
- No, this is an EPO plan. You must use in-network providers (except emergencies)
Q: Do I need a referral to see a specialist?
- No, you can see any in-network specialist without a referral
Q: Is dental and vision covered?
- Limited coverage: Adult eye exams (1/year) and children's eye exams (1/year) are covered. Routine dental and children's glasses are NOT covered.
Document Version Information
- Version: 1.0
- Effective Date: January 1, 2026
- Expiration Date: December 31, 2026
- Plan Administrator: Mascorp Management Corporation
- Plan Type: EPO (Exclusive Provider Organization)
This Knowledge Base article contains all details from the official Summary of Benefits and Coverage document. For the complete terms of coverage, contact 1-888-832-0354 or refer to the full plan document.