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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.

This Membership Summary Access 2019 that has been published by Sedera presents an excellent short summary of the features of the medical cost sharing portion of the program.

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

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

All expenses must be medically necessary to be considered eligible for sharing.

• 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. Not shareable for convenience purposes only.

• 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. Related items for treatment such as prescribed 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 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 the MEC used in the Partially Self-Directed or Provider-Directed Healthcare option, as applicable, or by your Direct Primary Care doctor if you’ve selected the DPC-Direct Primary Healthcare option. The Sedera MCS Community will not share in laboratory diagnostics for which the practice receives a kickback or upcharges more than 10% over the available wholesale lab price.

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

• Maternity Care –Medical expenses for childbirth 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; $7,500 for non-emergency or elective c-sections (irrespective of the IUA the member elects for other conditions when joining the program). 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 50% when using a birthing center. 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 the Partially Self-Directed Healthcare Program) or a Health Matching Account™ (Health Matching Accounts can be established with ANY of the three program options).

• 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 --Prescriptions for medication related to a qualifying medical condition are shareable for the customary cost of the first 120 days. Treatment for cancer and sublingual immunotherapy are not subject to this limitation; medications related to organ transplants are limited to 12 months’ duration. Sedera members do not share the cost of prescriptions for maintenance of chronic or recurring conditions (e.g. diabetes, eczema, and blood pressure control) beyond the initial 120-day period. Subsequent sharing of a prescription for maintenance of the same condition will occur only when there is a new Need. Contact your Member Advisor or Wellness Coordinator to find significant discounts on medications (irrespective of whether 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.

• Psychiatric Care—Inpatient psychiatric care is shareable up to $5,000 per condition. Outpatient psychiatric care or services are shareable to a maximum of $1,500 per separate Need. See the Access Sharing Guidelines for specific details and limitations.

• Preventive Services—Preventive care services are generally not shareable under the medical cost sharing portion of the program. However, colorectal screening colonoscopies for members 50 or over; breast cancer screening mammograms for women 40 or over; and vaccinations and immunizations for children from birth through age 18 are shareable as outlined in the Guidelines. 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 portion of the program.

• Speech, Physical and Vision Therapy—Speech therapy is limited to 25 outpatient visits per condition, to a maximum of $2,500 per separate Need. Physical therapy is subject to 20 outpatient sessions per Need to a maximum of $2,500 per separate Need or for up to 180 days, whichever occurs first. Vision therapy is subject to a 25-visit maximum per Need to a maximum of $2,500 per separate Need. In general, no other therapies are shareable.

• 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 three preventive care services that meet the criteria specifically mentioned in the Guidelines (there is NO IUA for such services), ALL shareable expenses must be part of a Need and are eligible for sharing ONLY after the Initial Unshareable Amount (IUA) threshold is reached.

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ALTERNATIVE MEDICAL PRACTICES

As determined by Sedera’s Community Stewardship Board, alternative treatments including ayurvedic, acupuncture, homeopathy, naturopathy, functional/integrative medicine and any practice that is unproven or insufficiently proven are not shareable. Nutritional supplements, detoxification, use of diagnostics and therapeutics for mold toxicity, chronic Lyme and other poorly characterized conditions, stem cell therapies (other than where proven effective) and all diagnostics and lab tests performed on healthy people other than screening testing as recommended by the US Preventive Task Force are also unshareable.

Alternative therapeutics may be considered for limited (partial) sharing if Sedera’s Community Stewardship Board is provided convincing evidence of the value/effectiveness for the specific disease being treated. Your Sedera Member Advisor or Needs Coordinator is available to discuss the submittal process to the Community Stewardship Board.

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HOW WILL MY BILLS BE PAID?

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

Bill payment procedures are described in Section 10 of the Access Membership Guidelines.

You should call Sedera and submit expenses that may qualify as Needs by using the Needs Processing Form. Sedera recommends submitting a 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.).

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 Unshareable 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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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:

  1. 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.
  2. I understand that Sedera, Inc. is a benevolence organization that facilitates the Sedera Medical Cost Sharing Community, 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 expense.
  3. I agree to practice good health measures and strive for a balanced lifestyle.
  4. I agree to refrain from the usage of any form of illegal substances.
  5. I understand that medical needs caused by, or due to, the act of performing any illegal or unlawful activity will not be shareable.
  6. I agree to submit to mediation followed by subsequent binding arbitration, if needed, for any instance of a dispute with Sedera, Inc. or its affiliates.
  7. I am an employee, member, or participant of a sponsoring entity that is providing access to the Sedera Medical Cost Sharing Community and am eligible for membership with the Sedera Medical Cost Sharing Community through that relationship. I understand that Sedera, Inc., by and of itself, does not make any representation that membership in the Sedera Medical Cost Sharing Community satisfies any federal or state law requirements for healthcare coverage or insurance.
  8. I agree to sign and submit a membership continuation agreement each renewal year confirming my commitment to adhere to these principles.
  9. I have read and understand all of the above, as well as the Sedera Membership Guidelines (including the Disclaimer and Section 12 Disputes and Reconciliation) and am certifying that all of my answers are true and accurate and indicate my agreement to abide by the Membership Guidelines as well as the Member Principles and Responsibilities.
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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.

At the same time, Sedera members, being cash-pay patients, are expected to seek reasonable prices for their medical care. Paying exorbitant charges for medical care ultimately leads to higher monthly costs of the entire community. Outside of bona fide medical emergencies, the Sedera Medical Cost Sharing Community and its members are disinclined to share in expenses generated by physicians and facilities who charge hyperinflated and exorbitant prices and are unwilling to negotiate for fair prices. Once informed by Sedera, Inc. that a provider or facility charges exorbitantly and is not willing to negotiate reasonably, a member should not expect the Community to share in more than a fair and reasonable price as defined by industry norms if they choose to return to that provider. Sedera’s Member Advisors are available and happy to assist members in locating high-quality medical providers that charge fair prices for their services.

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

Most medical bills are grossly inflated. Therefore, member cooperation with bill negotiation is required on medical bills that exceed the member’s IUA. Members agree to authorize Sedera, Inc., and/or its affiliates, to negotiate billed charges on their behalf. Members who refuse bill negotiations negatively impact the entire Community. Consequently, Sedera, Inc. reserves the right to reduce the amount shared by 50% off billed charges over $500 in cases where a member refuses authorization to negotiate on their behalf.

If you select 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 option are provided under an EPO (Exclusive Provider Organization) offered through APEX. This means that preventive care services must be provided through a PHCS network provider and there are no preventive care benefits provided on an out-of-network basis. Please refer to the Prevent portion of the strategy to find PHCS providers.

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PRE-EXISTING 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.

Charges for a cancer that occurred prior to membership that recurs after membership are not shareable; however, charges for a cancer that is not related to cancer of a type the member had prior to becoming a member are shareable.

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
  • Treatment for hemorrhoids

Medications for high blood pressure and high cholesterol 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, Inc. 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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Review the 3 types of programs
health excellence plus

SELF-MANAGED PROGRAM OPTIONS
Partially Self-Directed Healthcare
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
DPC - Direct Primary Healthcare
DPC - Direct Primary Healthcare
Provider-Directed Program Supplementing Direct Primary Care With Wellness Services AND Medical Cost Sharing Plan For Large Expenses, Screening Colonoscopies And Mammograms, And Childhood Immunizations/Vaccinations
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Provider-Directed Healthcare
Provider-Directed Healthcare
Provider-Directed Program Combining Wellness Services, Redirect Health for Preventive Care And Most Small Expenses, AND Medical Cost Sharing For Large Medical Expenses

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