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Medical Cost Sharing For
Large Medical Expenses

CONTAIN
- with Medical Cost Sharing

contain

CONTAIN MEDICAL COSTS

You can't AVOID, PREVENT, MANAGE, or MITIGATE all your medical costs.  You'll need to CONTAIN the rest with Medical Cost Sharing.

With Medical Cost Sharing like-minded, health-focused members band together to share each other's medical costs above an amount they can comfortably afford. Medical Cost Sharing is based on the principles of what are called Christian health care sharing ministries.

There are NO religious requirements for membership. All services must be medically necessary.

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Shareable Expenses
1
Alternative Treatments
2
Bill Payment
3
Bill Negotiation
4
Treatment Outside USA
5
Medical
Tourism
6
Naturopathy
7
No Maximums
8
Membership Principles
9
Open Access
10
Pre-Existing
11
Sedera Advisors
12
Smokers
13

MORE DETAILS:

Expenses are eligible for sharing based on a “Need”.  Medical expenses related to the same medical condition, including those for separate incidents [e.g. separate treatments (or episodes) of symptoms] where such expense exceeds the applicable Initial Unshareable Amount are considered one Need.] 

Needs are limited to a maximum of three Needs per individual and 5 Needs per membership unit in a membership year. Once an individual or membership unit incurs this number of Needs in a membership year, there is no Initial Unshareable Amount for any other services recognized as shareable in accordance with the Access Membership Guidelines. Experience is that the average family has only 1.8 Needs per membership year.

Unlike traditional insurance which resets deductibles each calendar year, a Need exists (and only has ONE IUA that occurs in the first year) as long as the condition exists. If a person has treatment for a Need within a 12-month period the Need continues and the IUA does not re-set unless and until no treatment occurs for at least 12 months.

Limitations and Restrictions:  

Most conditions are fully shareable in accordance with the Guidelines, but the Guidelines place some limitations on types of physical maladies and medical services for which Needs are shared, and certain conditions are excluded from sharing. See Sections 8 and 9 of the Access Membership Guidelines for details. 

Unless a condition is shared or restricted in accordance with the Guidelines there is no lifetime limitation on the amount of expenses that can be shared.

Analysis conducted in May 2017 by Sedera showed that members saved an average of 57% of medical costs just by being a member of the Medical Cost Sharing community.  This is in addition to the savings resulting from lower monthly share contributions.

Note:  Sedera Medical Cost Sharing is not insurance and therefore is not regulated by state departments of insurance or consumer affairs or by the federal government.



SHAREABLE EXPENSES

• Accidents-- Any payments received by third party medical payors, who are expected to pay first, are first applied against the Initial Unshareable Amount (IUA) for the specific Need.

• Ambulance Services--Whenever medically indicated by a licensed medical doctor and/or whenever practical due to the severity, proximity and circumstances associated with a specific illness or injury.

• Chiropractic--Up to a maximum of 15 office visits and $1,500 limit per Need if services are related to treatment of a specific musculoskeletal injury or musculoskeletal disease. Prescribed nutritional supplements for up to 120 days and x-rays are included. Maintenance treatments are not shareable. All other chiropractic services will be treated as Alternative Medical Practices.

• Hospitalization--Shareable at semi-private room rate or if a licensed medical provider prescribes ICU or quarantine.

• Hospital Emergency Rooms and Urgent Care Facilities--Generally shareable for medically necessary services resulting in expenses that exceed the IUA threshold.

• Laboratory Tests and Check-ups--Shareable only when prescribed by a licensed medical provider due to symptoms of a condition not in existence prior to membership. Routine check-ups and associated laboratory testing may be covered under one of the MEC's available under the program.

• Long-Term Care/ Skilled Nursing/ Visiting Nurses--Shareable as a result of recovering from an injury or illness as prescribed by a licensed medical provider. Sharing is limited to 90 days per medical Need. Nurse visits are shareable for up to 25 days following a hospitalization stay.

• Maternity Care –Medical expenses for child birth that have an expected delivery date within the first 12 months of membership are not shareable. Maternity benefits have a separate individual unshareable amount (IUA) from other conditions: $5,.000 for normal delivery and emergency c-section; $7500 for non-emergency or elective c-sections (regardless of the IUA the member elects for other conditions when joining the plan). Miscarriages are shared based on the regular IUA the member selects.

Shareable maternity needs include expenses for pre-natal care, delivery, post-natal care, miscarriage and congenital conditions. The member's IUA is reduced to $500 for home births and 50% when using a birthing center and for vaginal birth after Caesarean (VBAC). Bills for all pregnancy and birth-related complications of the mother will be shared as part of the maternity Need. Routine post-natal care of the child, including no more than one routine outpatient doctor visit, will be part of the mother’s maternity Need. Any pre-birth need of the child or a post-birth need of the child beyond routine natal care will be considered a need separate from the mother's maternity Need. Note: members considering having a baby should consider establishing a Health Savings Account (if the member selects a MEC with a high deductible health plan) or a Health Matching Account™.

• Medical Equipment Rental/Purchase --Medical equipment rental/purchase is shareable for the first month if prescribed by a licensed medical provider up to the maximum amount of the cost of purchase of the item. Rentals after the first month and all purchases require prior written approval.

• Medical Supplies--Generally shareable for the first 120 days of treatment as prescribed by a licensed medical practitioner.

• Outpatient Prescription Drugs – Outpatient medications are shareable as part of a Need. The diagnosis must have occurred after the membership effective date. There is no time limit for how long curative medications are shareable, whereas maintenance medications are shareable for a maximum of 120 days. The Medical Advisory Group makes the determination whether and when a medication is for curative or maintenance situations. Contact your Member Advisor or Wellness Coordinator to find significant discounts on medications (whether or not they are eligible for sharing), and utilize the World Meds and other programs to find significant discounts on brand-name drugs as well as higher-priced generic medications.

• Physicians' Office Visits--Shareable only if part of a Need that meets the IUA threshold.

• Physician Services--Surgeons, assistant surgeons, anesthesiologists, physicians' hospital visits, physicians' office visits, etc.

• Preventive Care--Preventive care services are generally not shareable under the medical cost sharing portion of the program. However, preventive mammograms for members 50 and over and colonoscopies (for members 40 and older), and childhood immunizations and vaccinations (excluding flu shots) that are medically appropriate for the member's age and condition are fully shareable (i.e. there is no IUA for these services). Note: If the member's program has a MEC, these services are covered under the terms of the MEC, and it will benefit the community if the member obtains these services under the MEC instead of the Medical Cost Sharing program.

• Therapies--Shareable for various therapies related to injuries or disease. Subject to 25 outpatient sessions per Need to a maximum of $2,500 per separate Need. (All types of therapies, e.g. speech, occupational, physical, respiratory, etc., are considered against the maximum.)

• All Other Eligible Expenses – Paid in accordance with the Access Membership Guidelines.

THE ACCESS MEMBERSHIP GUIDELINES CONTAIN THE AUTHORITATIVE DESCRIPTION OF WHAT IS SHAREABLE UNDER THE PROGRAM, and expenses are shareable ONLY for a Need as defined in those Guidelines. The Access Membership Guidelines govern in the event of any conflict between this summary and the Access Membership Guidelines.

Except for the specific preventive care services mentioned above, ALL shareable expenses must be part of a Need and are eligible for sharing ONLY after the Initial Unshareable Amount (IUA) threshold is reached. There is NO IUA for the preventive care services specifically mentioned above.

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ALTERNATIVE MEDICAL PRACTICES

Shareable pending prior written approval by Sedera (the medical cost sharing administrator). The member is required to demonstrate the proposed value of the prescribed alternative treatment, e.g. monetary savings, less-invasive treatment, shortened treatment protocol, etc.

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HOW WILL MY BILLS BE PAID?

Sedera Health (the medical cost sharing provider) makes payment directly to you and you are responsible for paying the health care provider.

You should call Sedera and submit expenses that may qualify as Needs by using the Needs Processing Form. Sedera recommends submitting a Needs Processing Form as soon as you can if you think the expense will qualify as a Need. Otherwise, you should wait until you have met your Individual Unshareable Amount for the Need and can provide the required information.

You can submit the Form using the Sedera mobile application or by mail. Make sure to retain all receipts and bills for all services and that you include all documentation that Sedera requires (your name and address, provider name and contact information, description of the diagnosis and treatment, etc.).

When Sedera receives the required information, normal practice is to pay you within 14-21 days for all expenses which count as shareable expenses under the Access Membership Guidelines unless Sedera is in the process of negotiating further with the health care provider. Otherwise, payment is made when negotiations are completed.

The negotiation process can take up to 60 days, but the health care provider knows there are negotiations proceeding, so you shouldn't be contacted by the health care provider if this process is occurring.

The Access Membership Guidelines state that a Need will normally be shared at the beginning of the second month after Sedera receives the Need, but it is our understanding that Needs are often processed with a faster turnaround. Sedera attempts to obtain further discounts for any expense that exceeds $500, but their objective is to be fair to BOTH the provider and the member.

Medical providers occasionally require up-front payment prior to delivering service. In these instances, members should make every effort to limit the up-front payment to their selected Individual Unshared Amount (i.e. $500, $1,000, $1,500, $2,500 or $5,000) and request to be billed for any remaining charges.

Members are encouraged to contact their Sedera Member Advisor prior to making large up-front payments to medical providers.

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MEDICAL BILL NEGOTIATION

Reducing Out of Pocket Expenses on Medical Bills

Members have access to a professional negotiating team at Sedera who is available to negotiate on their behalf to reduce medical bills. These skilled negotiators serve as trusted member advocates, expertly spotting things like hidden or duplicate fees, incorrect quantities and more.

When a member works with the Sedera team, not only does this service alleviate stress on the part of the member, it can also result in a significant reduction in out-of-pocket balances on medical bills for both the member and the community as a whole.

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TREATMENT OUTSIDE THE USA

Eligible needs, wherever incurred, will be handled through medical cost-sharing. Bills from medical treatments occurring overseas must be written or translated into English and the price converted to U.S. dollars.

They are then handled the same as bills from treatments in the United States and must be submitted on a Needs Processing Form (include information such as your name and address, provider name and contact information, description of the diagnosis and treatment, etc.).

The 2nd MD™ program is required for elective surgeries wherever performed.

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MEDICAL TOURISM

“Medical Tourism” is the term used for the process where people from one location travel elsewhere to receive medical and surgical care while at the same time receiving equal or greater care than they would have locally, and are traveling for medical care because of affordability, better access to care or a higher level of quality of care.

Some of the most well-known providers who are active in the Free Market Medical Association (the Surgery Center of Oklahoma is one example) are often referred by providers living elsewhere in the country to achieve one of the above objectives. The medical cost sharing program can recognize travel expenses as shareable when significant savings result and can be demonstrated.

Contact your Sedera Member Advisor to determine if expenses for medical tourism can be approved for sharing under the program. Sedera encourages medical tourism when demonstrable savings can be achieved without compromising access to or quality of care.

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NATUROPATHY

Naturopathy services are treated as "alternative medical practices" and shareable if prescribed by a licensed doctor of naturopathy upon prior written approval by Sedera.

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NO MAXIMUMS

There are no lifetime or annual maximum amounts eligible for sharing for most medical Needs. There is no limit on the number of Needs that you/your household may have. Some behavioral treatments and therapies do have annual sharing limitations (see Section 8 of the Access Membership Guidelines).

Tobacco users age 50 and older have a $25,000 shareable limit for cancer, heart conditions, COPD, and stroke until they are confirmed as being tobacco-free for 12 months.

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PRINCIPLES OF MEMBERSHIP

Enrollment in medical cost sharing requires agreement to strive for a healthy lifestyle, no use of illegal narcotics, and no driving while intoxicated.

All prospective and current members must agree with and attest to the following statements:
  • I believe that a community of moral, ethical and health-conscious people can most efficiently and effectively encourage and care for one another by sharing each other's medical needs directly.
  • I understand that Sedera Health is a benevolence organization, not an insurance entity, and that while Sedera will make every effort to meet its members' medical needs, Sedera, in and of itself, cannot guarantee payment of any medical expenses.
  • I agree to practice good health measures and strive for a balanced lifestyle.
  • I agree to refrain from the usage of any form of illegal substances.
  • I understand that medical needs caused by, or due to, the act of performing any illegal or unlawful activity will not be shareable.
  • I am (1) an eligible member of a sponsoring entity's self-insurance MEC plan and am eligible for membership with Sedera through that relationship, or (2) I understand that membership in Sedera, by and of itself, does not satisfy the Individual Shared Responsibility provision of the Affordable Care Act, and that I may be responsible for applicable tax payments as a result of electing not to purchase a health plan that includes Minimum Essential Coverage. (Note: the Individual Shared Responsibility provision of the Affordable Care Act is eliminated effective January 1, 2019.)
  • I agree to sign and submit a membership continuation agreement each renewal year confirming my commitment to adhere to these principles.
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NO NETWORK LIMITATIONS - OPEN ACCESS

Medical cost sharing is a total open access program, which means there is no network (and no network limitations) in the medical cost sharing portion of the program that is provided through Sedera.

You can utilize any provider who accepts cash or credit payment. As a result, you’re not restricted by a network or surprised by "out-of-network" penalties.

Sedera will reimburse you for shareable Needs in accordance with the Access Membership Guidelines.

If you have selected the Partially Self-Directed Healthcare option, we highly recommend that you establish and fund a health savings account, obtain a debit card from your HSA provider, and present that card to your provider when you utilize services. This will facilitate provider acceptance and result in quicker reimbursement to you.

However, preventive and wellness care services under the MEC for the Partially Self-Directed Healthcare, Co-Pay Network Healthcare, and Direct Primary Healthcare healthy care options are provided under a EPO (Exclusive Provider Organization) offered through APEX.
NOTE: the MEC for the DPC-Direct Primary Care Healthcare Plan will not be offered to new members enrolling on or after January 1, 2019. Members who previously joined this plan will have the option of either retaining or dropping their MEC. Monthly share contributions will be adjusted accordingly.

These programs use the PHCS network. This is a large network, and you must use a network provider for covered preventive services to be covered at no cost.

Please follow these instructions to find PHCS providers. APEX also recommends that you check BOTH with your provider AND with PHCS at 800-922-4362, as in-network providers change frequently.

Redirect Health provides the MEC for the Self- Directed Healthcare option. Please contact Redirect Health at 800-922-4362 for details.

Remember that except for the MEC, Sedera (the health sharing portion of the program) is an open access program where you can choose any provider who accepts cash payment.

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PRE-EXISITING CONDITIONS

Except as indicated below, conditions that exist at the time of enrollment that have evidenced symptoms and/or received treatment and/or medication within the past 36 months are not eligible for sharing during the first year of membership.

During the second year of membership up to $15,000 of expenses related to the medical condition are eligible for sharing, and up to $30,000 is eligible for sharing in the third year.

Thereafter, the condition is no longer considered pre-existing and is eligible for full sharing in accordance with the Access Membership 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
  • High cholesterol counts controlled through medication and/or diet
  • Medical treatment for sleep apnea
  • Non insulin controlled diabetes

Medications for the above conditions are not shareable; maintenance medications for these conditions are shareable for up to 120 days only in situations where the condition occurs after the effective date of membership.

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SEDERA ADVISORS

The MyAHE Member Services Director will refer members to a Sedera Health Personal Member Advisor for additional help when needed for these types of services.

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SMOKERS

If anyone in a family unit smokes, there's a $75 monthly surcharge for that family unit.

Tobacco users age 50 and older have a $25,000 per Need sharing limit for the top four disease states associated with tobacco usage-- heart conditions, stroke, COPD, and cancer-- until they are confirmed tobacco-free for 12 months. See the Access Membership Guidelines for more information.

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Totally Self-Directed Program Combining Wellness Services AND Health Cost Sharing For Large Expenses And Mammograms, Colonoscopies and Childhood Immunizations
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Partially Self-Directed Healthcare
Partially Self-Directed Program Combining Wellness Services, Preventive Care, An Optional Health Savings Account, AND Medical Cost Sharing For Large Expenses
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PHYSICIAN-DIRECTED PLAN OPTIONS
Co-Pay Network Healthcare
Co-Pay Network Healthcare
Provider-Directed Program Combining Wellness Services, Preventive Care, Co-Pays For Most Small Expenses, AND Healthcare Cost Sharing For Large Expenses
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DPC - Direct Primary Healthcare
Provider-Directed Program Supplementing Direct Primary Care With Wellness Services AND Medical Cost Sharing Plan For Large Expenses And Mammograms, Colonoscopies, and Childhood Immunizations
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Provider-Directed Healthcare
Provider-Directed Program Combining Wellness Services, Redirect Health for Preventive Care And Most Small Expenses, Medical and Healthcare Cost Sharing For Large Medical Expenses
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