| Basic HSA Plan | HSA Plus Plan | PPO Plan | |
|---|---|---|---|
| HSA-eligible | Yes | Yes | No |
| Company contribution to HSA | $400 for employee-only coverage; $800 for family coverage | $650 for employee-only coverage; $1,300 for family coverage | None |
| In-network care: Your costs | |||
| Individual/ family deductible |
$2,000/$4,000 | $1,600/$3,200 | $800/$1,600 |
| Individual/ family out-of-pocket maximum |
$5,000/$10,000 | $4,500/$9,000 | $4,500/$9,000 |
| Coinsurance (applies after meeting deductible) |
You pay 20%, plan pays 80% | ||
| Office visit — Preventive care |
Covered at 100% in-network, so you pay nothing* | ||
| Office visit — Primary care | You pay 20% after deductible |
You pay 20% after deductible |
You pay $30 copay |
| Office visit — Specialist |
You pay 20% after deductible | You pay 20% after deductible | You pay $60 copay |
| Office visit – Chiropractor (60 visits per year) |
You pay 20% after deductible | You pay 20% after deductible | You pay $60 copay (services requiring adjustments/manipulation subject to deductible and coinsurance) |
| Telemedicine Physical Health | You pay 20% after deductible up to $59 | You pay 20% after deductible up to $59 | You pay $15 copay |
| Telemedicine (Behavioral Health) | You pay 20% after deductible | You pay 20% after deductible | $30 |
| Urgent care visit | You pay 20% after deductible | You pay 20% after deductible | You pay $60 copay |
| Emergency room visit | You pay 20% after deductible | You pay 20% after deductible | You pay $200 copay |
| Hospital (inpatient or outpatient) | You pay 20% after deductible | You pay 20% after deductible | You pay 20% after deductible |
| Mental health and substance abuse (inpatient) | You pay 20% after deductible | You pay 20% after deductible | You pay 20% after deductible |
| Mental health and substance abuse (outpatient) | You pay 20% after deductible | You pay 20% after deductible | You pay $30 copay |
*There is no cost if only a preventive exam is performed. If any other services are provided during the visit for new or ongoing health concerns, the visit may be billed as diagnostic and subject to the applicable charge for your plan.
Working spouse/domestic partner surcharge
If your spouse/domestic partner has group medical insurance coverage available elsewhere but chooses our program, $50 ($30 in 2023) will be added to your biweekly premiums each pay period. This helps Masonite to continue to offer comprehensive and affordable coverage for our employees.
This does not apply to dependent children. You will have to attest to the fact that your spouse/domestic partner is not eligible for group health coverage through his/her own employer by submitting a notarized form.
Non-tobacco rate for all medical plans