Plan document outline for an HSA-compatible, bare-bones health plan that integrates transparent pricing and Cost Plus Drugs.

What follows is a regulatory-compliant structure — something that could evolve into an actual Summary Plan Description (SPD) and Evidence of Coverage (EOC) if you partnered with a licensed carrier or self-funded employer group.

🏛️ ClearHealth Basic HDHP

Plan Outline – Draft for Legal/Regulatory Documentation

1. Plan Overview

Plan Name: ClearHealth Basic HDHP Plan Type: High Deductible Health Plan (HSA-Compatible) Plan Sponsor: [Your Entity Name, LLC] Administrator: ClearHealth Administration Services Plan Year: Calendar Year 2026 (1 Jan – 31 Dec) Jurisdiction: United States (Compliant with IRS HDHP rules and ERISA §402(a))

Purpose: Provide affordable, transparent health coverage centered on patient choice, cost clarity, and HSA eligibility.

2. Eligibility and Enrollment

Eligible Participants:
- Individuals or families residing in participating states.
- Must not be enrolled in any other non-HDHP coverage.
- Must not be claimed as a dependent on another tax return.
Effective Date: First day of the month following approval of application and initial premium payment.
Termination: Non-payment of premium, fraudulent claims, or voluntary cancellation with 30-day notice.

3. Definitions

Deductible: The amount you must pay each year before the Plan pays benefits.
Out-of-Pocket Maximum: The most you pay for covered expenses in a plan year.
Eligible Expense: A medically necessary service or supply performed by a licensed provider within the U.S.
Reference Rate: 120 percent of the Medicare Allowable Amount for the same procedure or service.
Direct Pay Service: A service purchased at a published cash price (e.g., Sesame, MDsave).
Cost Plus Drug: A prescription filled through Cost Plus Drugs at actual cost + 15 % + fees.

4. Schedule of Benefits

Category	Coverage	Notes
Preventive Care	100 % covered, no deductible	As defined under IRS Notice 2004-23/50 and ACA §2713
Primary & Specialty Care	Subject to deductible	Member pays cash rate or provider invoice
Telehealth Visits	$40 flat fee (applies to deductible)	May use partner network
Urgent Care & ER	Subject to deductible	Reimbursed at reference rate after deductible
Hospitalization	Subject to deductible → 100 % after met	Pre-certification required except emergency
Prescription Drugs	Cost Plus pricing (see Section 7)	Member pays direct until deductible met
Imaging & Labs	Member pays cash price until deductible	Eligible for HSA payment or reimbursement

5. Deductibles and Limits

Type	Self-Only	Family
Annual Deductible	$2,000	$4,000
Out-of-Pocket Maximum	$8,000	$16,000
Coinsurance (after deductible)	0 % (Plan pays 100 %)	0 % (Plan pays 100 %)

All qualified medical expenses under §213(d) of the IRS Code apply toward the deductible and OOP maximum.

6. Preventive Care Coverage

Services classified as preventive per ACA §2713 are covered at 100 %, including:

Annual wellness exam and screenings.
Immunizations.
Preventive lab tests and cancer screenings.
Prenatal and well-child care.

No deductible or coinsurance applies.

7. Prescription Drug Coverage

Administrator: Cost Plus Drugs Company

Structure:

Member pays the Cost Plus price (cost + 15 % + $3 pharmacy fee + $5 shipping).
All drug purchases are HSA-eligible.
After deductible is met, Plan reimburses the Cost Plus price at 100 %.
No PBM, no formulary restrictions.
Specialty medications handled case-by-case at negotiated rates.

8. Provider Network and Reimbursement

Open Access: Any licensed provider may render services.
Reimbursement Basis: 120 % of Medicare allowable amount.
Member Responsibility: Pre-deductible services paid directly via HSA or cash.
Claims Process:
1. Member or provider submits itemized bill.
2. Adjudication via reference-based pricing engine.
3. Reimbursement issued electronically after deductible met.

9. Exclusions and Limitations

Cosmetic or elective procedures.
Non-FDA-approved treatments.
Expenses covered by other insurance.
Care outside U.S. (except emergency).
Services not medically necessary under §213(d).

10. Coordination with HSA

Members may establish an HSA with any qualified custodian.
Contributions limited per IRS 2025 rules ($4,300 self-only / $8,550 family + catch-up).
Eligible expenses include deductibles, telehealth, prescriptions, and any §213(d) care.
Plan provides year-end reporting (Form 1099-SA / 5498-SA support).

11. Claims and Appeals Process

Submit claim within 12 months of service.
Decision issued within 30 days (urgent care within 72 hours).
First-level appeal within 180 days → review by Appeals Committee.
Final appeal may invoke independent review organization (§2719 ACA).

12. Stop-Loss and Catastrophic Protection

For self-funded employers or individual aggregators:

Reinsurance attaches after $50,000 per member per year.
Administered by [Reinsurer Name].

13. Disclosures

This Plan meets IRS requirements for HSA eligibility but is not a substitute for tax advice.
Preventive care coverage complies with ACA requirements.
Plan is subject to federal and state regulation as an HDHP or self-funded ERISA plan.

14. Administration and Contact

Plan Administrator: ClearHealth Administration Services Mailing Address: [PO Box / City, State, ZIP] Customer Service: 1-800-XXX-XXXX | support@clearhealth.life Appeals: appeals@clearhealth.life