Frequently Asked Questions
What kind of company is Sedera Health?
Sedera is a patient advocacy and benevolence organization. Sedera facilitates the sharing of medical costs between our participating Members (the community) and provides access to several 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 or injury that are greater than they can individually carry, 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 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 membership is on how our Members help one 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 healthcare system are the direct result of restricting personal freedom and responsibility through dependence on third-party payors. Sedera is designed to allow Members to help one another while maintaining freedom of choice and personal responsibility.
Does Sedera comply with the Affordable Care Act (“ACA”) or similar state law requirements?
Sedera’s Medical cost sharing is not insurance, so it does not comply with the ACA or similar state law requirements. However, your Sponsoring Entity (your Employer or the association through which you have access to Sedera) may provide additional products (such as a self-funded insurance plan designed to address preventive care) that complement Sedera and/or satisfy ACA or similar state law requirements. We recommend you connect with your Sponsoring Entity’s contact if you have specific questions related to legal compliance.
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 ACA’s requirements and don’t owe a penalty?
Sedera’s Medical Cost Sharing is not insurance, so it does not meet the ACA’s requirements. However, your Sponsoring Entity (your Employer or the association through which you have access to Sedera) may provide additional products (such as a self-funded insurance plan designed to address preventive care) that complement Sedera and/or satisfy ACA requirements. We recommend you connect with your Sponsoring Entity’s contact to obtain the required IRS documentation, if applicable.
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 fundamental to Sedera’s values. Sedera’s Member Advisors will be happy to assist you in providing quality information to help you decide 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 health insurance 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 remaining balance relative to that specific Need would be eligible for sharing, effectively reducing the member’s portion 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 your Sedera Membership.
What happens when a provider requires payment up front for services?
A Member may be required to pay out-of-pocket for medical services. 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. Sedera may pre-pay 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 sister company, The Karis Group (TKG), is a professional patient advocacy and medical bill negotiation company. 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 they enjoy.
How does Sedera handle medical claims?
Because there is no “transfer of risk” with Sedera’s Medical Cost Sharing, no “claim” is ever guaranteed. When Members incur medical expenses that exceed their IUA there is simply a medical need. Sedera Members submit proof of their medical expenses to Sedera where they are evaluated in accordance with the Guidelines. Qualified needs are then designated for sharing based on the amount of shares collected from Members each month. Each member’s monthly share is voluntary but also a requirement in order to remain an active participant in the membership.
What is the process for paying my medical bills when I have a need?
At the time of service, Members should disclose to their medical providers (doctors, laboratories, clinics, hospitals, etc.) that they are “self-pay” patients. 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 related 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. Sedera will review the need and help administer a process whereby community funds are share with the Member, less the Member’s IUA (as applicable), which, in turn, the Members use to pay their medical providers.
How long does it take Sedera to process a medical need?
The sharing turnaround time normally ranges from 14-60 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 Friday after Sedera receives it. Please note that larger bills make take longer to negotiate.
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 employment, membership, or participation in a Sponsoring Entity. Members must agree to abide by each of the nine 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 is no specific annual maximum dollar amount or lifetime maximum limits per member, though certain dollar amounts and/or visit limits apply to specific types of medical care and therapies. Sharing is only limited to the cumulative contributions received from participating members in any given month. There is, however no limit on the number of needs that an individual member or household may have. Additionally, no single need may consume more than one third (1/3) of the total number of shares available in order to assure ample shares for all members.
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. More than one million members have shared over a billion 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 people 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.” 90.1 percent of each member’s monthly shares are designated solely for assisting other member’s needs.
How do Sponsoring Entities pay for the Sedera Program?
All participating entities contribute shares directly on a monthly basis. Sponsoring Entities transfer the appropriate number of shares into their escrow accounts at the Designated Financial Institution. Each Sponsoring Entity initially decides how much of the monthly medical cost shares they will contribute if any, 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. Sedera may overlap needs from multiple months so that there adequate shares for all 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 the membership 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 or hospitals charges 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 Guidelines before it will be eligible for sharing. Because of the economic impact of very large medical bills (e.g., those over $150,000), 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 participating Sponsoring Entities 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?
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.