Medical Cost Sharing

Medical cost sharing is an arrangement whereby members agree to share one-another’s medical expenses through an act of voluntary giving.

Sedera is a patient advocacy and benevolence organization that provides a medical cost sharing membership program, as well as access to a number of ancillary health services.

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.

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 which can restrict 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.

Sedera is not licensed or registered by any insurance board or department since Sedera does not practice the business of insurance. Sedera does not assess applicants’ health risks, because neither Sedera nor its 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 its members help each another with their immediate needs.

The medical cost sharing membership that Sedera facilitates has no legal barriers within the United States of which we are aware.

No one is denied membership based on prior medical conditions. However, any needs that do not qualify according to the Sedera Membership Guidelines as shareable needs can still be made known to other members through Special Needs Sharing. In this way, members with non-shareable needs still have the opportunity to receive help from
other members.

Absolutely! Having the personal freedom to choose the medical providers of your choice is the cornerstone of Sedera’s program. Sedera and/or Redirect Health 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.

The Initial Unshareable Amount (IUA) is the amount of money ($500, $1,000 $1,500, $2,500 or $5,000 U.S. dollars) that members must pay their medical provider(s) prior to any amount being eligible for sharing. After the IUA has been paid for a qualified need, as determined by the Member Guidelines, becomes eligible for sharing consideration.

A qualified need is medical expense that exceeds the member’s Initial Unshareable Amount (IUA) caused by an injury or illness to an eligible member or dependent.

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 Member 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.

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). Sedera’s 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.

Members cannot be dropped from the Sedera medical cost sharing 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.

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.

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.

The Member 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.