What kind of company is Sedera Health?
Sedera is a patient advocacy and benevolence organization. Sedera provides the framework and administrative support for our group Medical Cost Sharing Membership, as well as access to a number of ancillary health services.
What is Sedera Health about?
Sedera believes that our Members, in concert with the medical providers of their choosing, have a natural incentive to do what is best for themselves and their families, as well as the primary responsibility for making their own health care decisions. When our Members have financial needs due to illness that are greater than they can individually bear, we believe that the Sedera community, in a corporate sense, should assist in carrying one another’s burdens. Our method of sharing each other’s medical bills seeks to teach these principles as an integral part of our community of sharing philosophy.
Isn’t Sedera really just another health insurance company?
No. Insurance arrangements are a contract whereby one party agrees to be legally responsible for and accept another party’s risk of loss in exchange for a payment—a premium. Medical cost sharing is an arrangement whereby Members agree to share one-another’s medical expenses through an act of voluntary giving. Sedera is not licensed or registered by any insurance board or department since we are not practicing the business of insurance. We do not assess applicants’ health risks, because neither Sedera nor our Members are assuming financial liability for any other member’s risk. Unlike insurance, the focus of Sedera’s medical cost sharing program is on how our Members help each another with their immediate needs.
What’s the advantage of Sedera not being a health insurance company?
When health care costs are paid by someone other than the person receiving care, typically an insurance company or government entity, the health care model can be undermined. We believe many of the current problems with the health care system are the direct result of restricting personal freedom and responsibility through dependence on third-party payors. Sedera Health is designed to allow Members to help one-another while maintaining freedom of choice and personal responsibility.
Does Sedera’s medical cost sharing program comply with the Affordable Care Act requirements?
Sedera’s medical cost sharing program is not a substitute for insurance as defined by the ACA. To deal with the requirements of the ACA, Member companies typically use a qualifying self-insurance plan (which includes Minimum Essential Coverage) administered by a licensed third-party administrator, or TPA. The self-insurance plan, however, is only designed to take care of preventative care needs and, in some cases, to provide a framework for qualifying for a Health Savings Account (HSA) program. Member companies also participate in Sedera’s Medical Cost Sharing Membership, so their employees have access to the assistance of many other Members in handling the costs of medical incidents that exceeds their Initial Unshareable Amount (IUA). For most medical incidents under the member’s IUA, Members will pay out of pocket or via their HSA, if they have set one up.
Is Medical Cost Sharing legal?
The Medical Cost Sharing Membership that Sedera facilitates has no legal barriers within the United States of which we are aware.
How will the IRS know that I meet the law’s requirements and don’t owe a penalty?
Typically participation in your employer’s self-insurance plan satisfies the IRS’ Individual Shared Responsibility (individual mandate) provision. Full details on the IRS’ reporting requirements are not in the scope of this document. Please note that Sedera cannot provide tax advice. Companies should consult their own legal and tax advisors for more information regarding compliance reporting for the health insurance mandates contained in the Affordable Care Act.
Can I choose my own doctors and hospitals without being penalized?
Absolutely! Having the personal freedom to choose the medical providers of your choice is the cornerstone of Sedera’s program. Our Sedera Member Advisors can assist in providing quality information to help you make a decision on the best provider(s), but there are no “out-of-network” penalties.
Does Sedera use deductibles and co-insurance?
Sedera’s process differs significantly from insurance practices in this regard; to our member’s advantage. Traditional healthcare deductibles are cumulative over the course of a plan year. Co-insurance is the portion of the medical expense owed by the patient. These insurance cost-sharing measures can amount to thousands of dollars in out-of-pocket costs to insurance policyholders annually. Conversely, when Sedera Members incur an eligible medical expense that exceeds their Initial Unshareable Amount (IUA), any amount above the IUA is then eligible for sharing, effectively reducing the member’s burden to the selected IUA for any single need.
Will Sedera share medical costs that were incurred outside of the United States?
Yes, Members’ eligible needs, wherever incurred, will be handled through Sedera’s medical cost sharing.
What happens when a provider requires payment up front for services?
Members are encouraged to use their HSA funds (if applicable) to provide payment for qualified medical services and equipment. If a Member does not have a HSA or does not have adequate HSA funds available, they may be required to pay out-of-pocket. Sedera advises its Members to avoid paying more than their IUA toward the cost of any medical need, as doing so dilutes Sedera’s ability to negotiate with medical providers. In cases where Members pay more than their IUA, they will be promptly reimbursed for the excess amount by the Sedera community. Additionally, Sedera occasionally provides direct up-front payment for proposed services. The most prominent example of pre-payment is with maternity cases. Very often Sedera pre-pays maternity cases, based on the provider’s self-pay rates, in advance of the baby’s delivery. In virtually all cases, needs payments are sent directly to Members, not to medical providers.
If there is no network, what is the method used to secure fair pricing?
All Sedera members are “self-pay patients.” This enables significant leverage in the negotiation of medical bills. Our parent company, The Karis Group (TKG), is a professional patient advocacy and medical bill negotiation organization. TKG currently serves nearly one million patient lives throughout the U.S. including negotiating all of the Needs for one of the largest Health Care Sharing Ministries in the nation. Sedera outsources the negotiation of all Member medical bills that exceed $500 to TKG. TKG’s average rate reduction exceeds 60% off billed charges. These savings are passed directly to our Members through the low monthly contributions you enjoy. However, please note that employer sponsored group plans typically do require a provider network.
How does Sedera handle medical claims?
Because there is no “transfer of risk” in Sedera’s health care sharing program, no “claim” is ever owed. When Members incur medical expenses there is simply a medical need. Sedera Members send proof of their medical expenses to the Sedera office where they are evaluated according to the Guidelines. Qualified needs are then designated for sharing based on the amount of shares collected from the Member each month. Each member’s monthly share is voluntary, but is also a requirement to remain an active member.
What is the process for paying my medical bills when I have a need?
At the time of service, Members should present themselves as “self-pay” patients to their medical providers (doctors, laboratories, clinics, hospitals, etc.). The providers will, in turn, bill the Member directly. The Member then organizes their bills, fills out a Need Processing Form (NPF) and submits the NPF, copies of all relative medical bills and any proof of payments made towards their Initial Unshareable Amount (IUA). Our team of medical bill negotiators may contact the providers to discuss the appropriate payment for the services that were performed and determine if negotiations are necessary or available for the billed amounts. Members will receive the appropriate number of shares from Sedera, which, in turn, they use to pay their medical providers.
How long does it take Sedera to process a medical need?
The sharing turnaround time ranges from 15-60 days from receipt of your bills and required information depending whether negotiation is required or not. If your Need Processing Form is correct and complete, and there are no ongoing financial negotiations with providers, your need will normally be shared the second Wednesday after Sedera receives it.
How would medical emergencies be handled for international travel situations?
Medical needs incurred internationally would be sharable with the community in the same way as any other legitimate medical need within the U.S. If the member’s out-of-pocket costs exceeded their Initial Unshareable Amount (IUA) for a particular need while overseas, the Member would simply provide Sedera the details on the costs incurred along with any amount paid by the Member, and Sedera would facilitate sharing the portion that exceeds the member’s IUA.
What are Sedera’s Membership requirements?
Sedera Members are eligible through their employer’s health and welfare program or through their Association membership. Members must agree to abide by each of the eight Principles of Membership. See Sections 1 and 2 of the Member Guidelines for the details of Membership requirements. Members understand that medical expenses resulting from the use of illegal drugs, or while participating in unlawful activities will not be shared.
Is there a lifetime or yearly maximum amount that is eligible for sharing for any one person or family?
There are no lifetime or annual maximum amounts eligible for sharing for most medical needs. Certain sharing limitations exist for specific health conditions such as; mental health/chemical dependency and various forms of therapy. However, there is no limit on the number of needs that an individual Member or household may have in a given Membership year. In the event that the collective needs requested by the community exceed the number of shares available for a particular month Sedera may use a prorating contingency plan.
How can I be sure that Sedera really works?
The concept of medical cost sharing has been highly successful within the confines of faith based Christian groups for more than 25 years. Nearly one million members have shared hundreds of millions of dollars in medical expenses over that span of time. Hence, there is strong precedence in the concept. We believe that a community of health conscious individuals who care for their fellow man can successfully participate in the sharing of one-another’s medical burdens. It is important to note that past successes by faith-based sharing groups assisting one another is no guarantee of the future success of similar programs. There is no promise or contract by Sedera or the Members to contribute toward any need you might have in the future. The only promise by Sedera is to facilitate the voluntary shares given through the medical cost sharing process. Sedera distributes these monthly contributions on behalf of those Members with needs.
Does Sedera charge monthly premiums?
Because Sedera’s medical cost sharing Membership is not insurance there are no premiums. Sedera Members freely choose to assist other Members with their medical expenses by contributing a predetermined amount each month; called a “share.” Ninety point one (90.1) percent of each member’s monthly shares are designated solely for assisting other member’s needs.
How do Groups pay for the Sedera Program?
All participating entities contribute shares directly on a monthly basis. Groups (employers or Associations) transfer the appropriate number of shares into their escrow accounts at the Business Bank of Texas. The entity initially decides how much of the monthly medical cost shares they will contribute and how much will be contributed by the member.
What happens if there are more medical needs than available shares in a month?
Sedera’s Guidelines clearly state the reality that payment is never guaranteed, but is always based on the commitment of the Members to each other. Sometimes Sedera can overlap needs from multiple months so that there is enough money for all the needs. However, if all needs cannot be met, Sedera uses a prorating method to evenly distribute the burden. For example, if there is only enough shares available for 90 percent of the needs submitted for a particular month, Sedera can only commit to sharing 90 percent of each need.
Can my Membership be dropped if I have very high medical needs?
Members cannot be dropped from this program due to their medical needs. Neither your Membership nor your monthly share is affected by the amount of medical expenses you or any family members may have.
What kinds of needs do Sedera Health Members share?
In general, needs for illnesses or injuries resulting in visits to licensed medical providers, emergency rooms, diagnostic testing facilities, laboratory fees or hospitals are shared on a per person, per incident basis. See Sections 6-9 of the Member Guidelines for details.
How can I know if a need qualifies for sharing?
The types of needs that qualify for sharing can be found in the Member Guidelines. Consult Section 10 to familiarize yourself with the general procedures for submitting your need and Sections 6-9 for the specific requirements for sharing certain types of needs. If you have any questions, do not hesitate to call your Sedera Member Advisor at 1-855-973-3372.
How does Sedera handle very large medical expenses?
There is no maximum limit to the amount that Sedera will share towards a specific medical need. However, the need must be within the scope of the Member Guidelines before it will be eligible for sharing. Because of the economic impact of very large medical bills (e.g., those over $100,000), Sedera has devised an internal mechanism to ensure that adequate shares are available to meet both our member’s normal and high-cost needs. For the very large medical expenses that occur from time to time, Sedera makes provision by allocating 15% of member’s monthly shares to remain available through a separate escrow fund that Member companies have established. Sedera reserves the right to negotiate medical expenses with providers, and to prorate available shares, as necessary, in order to address all member’s medical expenses.
Are there any specific medical conditions that have an exclusion or waiting period?
The Guidelines state that health conditions that have been diagnosed or that have exhibited observable symptoms within 3 years of the Membership effective date will not be sharable for a period of time. Are there any specific medical conditions that have an exclusion or waiting period? A look-back period of 36 months applies to all prior medical conditions for Sedera applicants. A prior medical condition, as previously defined, is a condition in which the applicant has either received medical treatment, taken medications for, or exhibited observable symptoms. Any prior medical condition that has not exhibited symptoms during the 36 continuous months prior to membership effective date is considered cured and will have no sharing restrictions. Prior medical conditions will become eligible for sharing based on the Member’s tenure with Sedera, as indicated by the guidelines. Sharing restrictions do not apply for high blood pressure, as long as the member has not been hospitalized for high blood pressure in the 36 months prior to membership and the condition is controlled through medication and/ or diet. However, medication for treatment of high blood pressure as a chronic condition will not be shared.
What if I lose my job or change employers? Can I take my Sedera membership with me?
Continuation of Membership in Sedera’s Medical Cost Sharing program after termination of employment is dependent on, 1) Whether the participating employer provides COBRA continuation coverage of their self-insurance group plan, and 2) Whether the former employee chooses to exercise their federal COBRA option to continue their group plan. If the participating employer provides COBRA benefits, and the former employee elects to continue their group plan, they may continue their Sedera Membership as well. Former employees also have the option to enroll in individual health insurance coverage through their state or federal insurance Marketplace within 60 days of termination of their employer’s group plan. Additionally, any HSA funds that the Member may have accumulated during their employment are also fully portable after termination of employment.