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health excellence plus

Who Benefits Most From The Program?




The program uses a variety of funding and delivery mechanisms that differ from conventional insurance. The person who obtains the most value from this program (1) is not eligible for significant subsidies under the Affordable Care Act, (2) is healthy or health-focused, and (3) has a different mindset from the person who purchases conventional health insurance. The individual takes personal responsibility in actively managing his or her health, and exercises freedom of choice in how he or she attains health and wellness.

As a result of participating in Health Excellence Plus the member is exempt from tax penalties under the Affordable Care Act; takes an active role in managing his or her healthcare costs; and has the opportunity for SIGNIFICANT cost savings (50% or more over conventional insurance).

Group medical cost sharing is an important part of the five-tier strategy. The program is designed for health conscious people who strive to live a healthy lifestyle.  It may not be appropriate for those with pre-existing conditions, smokers, conditions that may be limited in some way under the  Membership Sharing Guidelines or those who qualify for large subsidies under the ACA. However, no one is denied membership on the basis of health status, although medical conditions that existed prior to membership may be limited or excluded from sharing.


Who's Eligible To Join?

You're eligible to enroll in Health Excellence Plus if you become employed as an MPowering Benefits LLC contractor by completing a health risk assessment (this is a "living risk assessment" because it gives you the ability to continually update the assessment and create new goals when you achieve previously-established goals) and then refer at least one person per year who becomes a member and remains enrolled for a minimum of 60 days. You'll be compensated $25 for completing the assessment and $100 for each qualified referral. You'll receive a 1099 and, as such, qualify for group membership and are eligible to participate in the program.  

You must complete the health risk assessment when you first join the program.  If you do not receive income for a health risk assessment or an enrollment in a specific year you'll be eligible for COBRA for up to 18 months and can continue in the program by making the same monthly share contributions.  If your participation in the program ends due to exhaustion of COBRA or by not electing COBRA when it is initally offered, you'll be considered having a qualifying life event and will be able to enroll in an Affordable Care Act plan within 60 days of the occurrence of that life event.

Health Excellence Plus is also available to employers of from 5 to 50 employees.  The employer has different options for setting up the preventive care portion of the program (the employer has a choice of third party administratiors, including the one used in this program). If the employer chooses the MEC Plus program as outlined below, the five tiers and monthly share contributions are the same as outlined herein. However, the employer can choose a different third party administrator that offers different benefits, and this does effect program elements and monthly chare contributions.  Please call us at 877-734-3884 for details if you are an employer and are interested in offering this or a similar program to your employees.

Self-Pay Patients






The best way to take control of and reduce healthcare expenses is to become a  self-pay patient (this is a term used to describe someone who chooses to pay for their treatment directly and elects to become a member of a group of like-minded, health-focused people, just like themselves, that agrees to share any costs they incur above an amount they can comfortably handle). Self-pay patients are wise and educated consumers of health care services and ask for discounts when they pay for and receive services from providers. Sedera (the medical cost sharing administrator) helps negotiate these discounts further for bills that exceed $500 when bills are submitted. Sedera suggests that members never pay a provider more than $500 in advance of receiving a service, as this can affect Sedera's ability to negotiate additional discounts.  If a provider requires or requests more than a $500 payment, members should call Sedera for assistance.

In virtually every transaction you make EXCEPT FOR MEDICAL CARE, you always know or negotiate the price up-front and shop accordingly.  This process is called PRICE DISCOVERY and is lacking in conventional health insurance where the focus is on co-pays, deductibles and coinsurance INSTEAD of the cost of the service. Health Excellence Plus introduces price discovery into the purchase and utilization of healthcare services! 

As an example of what self-pay patients can save on their health care costs, true self-pay patients generally pay approximately 6.06% of what they are billed by hospitals, according to an article by Kelly Gooch in the Hospital CFO Report dated March 2, 2017.  Self-pay patients often save 1/3 to 1/2 on their doctor bills, as well. Such patients also strive to be healthy and live a healthy lifestyle. 


How Much Does It Cost (How Much Are Monthly Share Contributions)?

There's an initial enrollment (administration and set-up) fee of $150 and a yearly administrative fee of $50 for the entire program.  In addition, you pay monthly share contributions in accordance with the box, below.



Membership Type $500 Initial Unshareable Amount
(Monthly Share Contribution)
$1000 Initial Unshareable Amount
(Monthly Share Contribution)
     
Individual $299 $249
Couple $599 $485
Parent With Child(ren) $520 $427
Family $786 $638
     
  All Members Under Age 30:  
     
Individual $250 $215
Couple $537 $440
Parent With Child(ren) $452 $408
Family $713 $586

Note: Amounts are based on paying by EFT; amounts are increased $15 per month if payment is made by credit card.

The Healthy Care Strategy For Controlling and Reducing The Cost of Healthcare


AVOID: WellFit Wellness Program To Eliminate Medical Costs




The WellFit Wellnesss program is provided through My Academy of Health Excellence.  

Get and stay well and eliminate medical costs. Complete the required Living Risk Assessment, identify your potential health risks, follow the recommendations, participate in the educational modules, set goals and track your progress. Get healthier, feel better and save money. This complete set of continuously improving and innovative health and wellness tools and incentives is designed to educate you, keep you healthy and/or improve your health--with the objective of avoiding use of healthcare services in the first place.

Click on each tab to learn more about the components of the WellFit Wellness Program:




New members schedule a one-on-one session with the Director of Member Services or one of his staff members to learn about all the features of the program, answer their questions, and receive help in enrolling in services such as TelaDoc.  The Director of Member Services explains what it means to be a self-pay patient and emphasizes the importance of the health and wellness program's features to AVOID incurring medical costs in the first place.

There can be a learning curve as a self-pay patient when navigating the healthcare world with billing issues, finding the best doctors to suit your needs, and making the best use of your money such as when obtaining a cat scan, MRI, finding the best prices on medications, etc.  The Director of Member Services is available to help you with issues and questions such as these if they arise once you're a member of Health Excellence Plus.

Everyone is unique and different.  By participating in this program and engaging with your Academy of Health Excellence Wellness Coordinator, we  work with you to identify the particular area of health and wellness most important to you and customize a program with actionable results to help reach your goals.

Specific programs are:

  • Personal – uniquely configured solutions address specific participant needs.
  • Secure – data access, storage and transmission meet stringent HIPAA and HITECH compliance standards.
  • Trusted – developed and managed by board-certified, NCQA certified physicians.
  • Fun – exciting and engaging programs to track progress and manage incentives. We provide effective engagement with members in their health & wellness—sparking wellness interests and participation, engaging members with their healthcare needs, motivating sustainable strategies, and provide clinics and coaches with proactive outreach to the members they serve.


You must complete the required Health Risk Assessment (we refer to this as a "Life Risk Assessment" because our tool permits you to use a continuous process of establishing and then re-establishling goals once previous goals are attained) as a condition of employment as an independent contractor with MPowering Benefits. Identify your potential health risks, follow the recommendations, participate in the educational modules suggested, set goals and track your progress. Get healthier, feel better and save money. 

You'll be paid $25 for submitting your Life Risk Assessment, and completion of the Assessment is a condition of employment as an independent contractor with MPowering Benefits in order to qualify for enrollment in Health Excellence Plus.   

In order to remain employed as an independent contractor of MPowering Benefits and continue to be enrolled in the program, you must also refer at least one member who enrolls and remains enrolled for at least 60 days in a calendar year. You'll be paid $100 for each referral who meets these requirements.

If you lose your employment status as an independent contractor of MPowering Benefits after you enroll in the program. you'll be entitled to elect COBRA. You can regain employment status and be re-enrolled in the program if you refer a member who enrolls and meets the 60 day requirement while you are on COBRA.

Alternately, loss of employment as an independent contractor is considered a qualifying life event under the ACA and as an option you'll be able to enroll in an individual or family ACA plan within 60 days of loss of employment as an independent contractor.

This exciting wellness program is a collaborative effort between world-renowned wellness expert Dr. Kerry Olsen and his Mayo Clinic team’s Twelve Habits of Highly Healthy People and Mikropis' (a global tech company) 24alife initiative. 

The program has identified twelve individual habits most crucial to highly healthy people. 

One of the twelve habits is selected monthly as part of a year-long wellness program carefully designed to guide you to meaningful and permanent habit change at any age and every stage of life.


MyQR Life Codes give first responders accurate-up-to date personal and health information in case of an emergency.  The codes are provided free of charge to all members. Labels, tags, and wrist bands (as well as key fobs) containing the code can also be ordered to wear on shoes, helmets, lanyards, ID badges and other personal belongings. 

Users can also (1) store and review medical files; (2 record health-related observations; (3) receive medication reminders; (4) contact doctors and caregivers; and (5) share health records, personal health diaries and photos. Additional free and fee-based services are in development.

MyQR LIfe Codes and MyHealth.Us are fully HIPAA compliant.


These include the monthly Health Excellence Newsletter that is sent to all members; seminars and webinars with health and wellness experts; direct mail, email campaigns and text messaging on health and wellness subjects; and the WellFit Wellness mobile application.

The WellFit Community enables you to connect, communicate, contribute and collaborate with other like-minded members.  

The Community provides helpful tools and membership in an interactive wellness community, including participation in a choice of health specific groups (e.g. stress reduction, fitness and exercise, age management, etc.) to help you identify and achieve your individual health and wellness goals. 





PREVENT: Preventive Care Services Provided Through A Preventive Care "MEC"


This is a self-funded PPO offering a plan of minimum essential coverage ("MEC") administered by a third party administrator.  There's no charge for in-network preventive services determined by the U.S. Preventive Services Task Force as required to be covered by ACA (Obamacare) plans. If a member decides to use an out-of-network provider for one of these services, s/he pays the provider directly and is eligible for reimbursement of 130% of the Medicare Allowable expense for that service..

The MEC utilizes the PHCS network in all states except California, where it uses the Network By Design network. These are large networks. PPO network providers change frequently, so it's best to call 800-922-4362  (for PHCS) or 209-229-8537 (for Network By Design) to confirm or find providers.  If you call, mention MPowering Benefits LLC and that you are a current or prospective member of Health Excellence Plus

Preventive services are one of Obamacare's Essential Health Benefits. Preventive coverage provided under a self-funded plan meets the federal government's requirements for Minimum Essential Coverage for a small group plan (generally under 50 full-time employees). Accordingly, the plan satisfies the Employer Shared Responsibility Mandate for Minimum Essential Coverage as well as the Individual Mandate and therefore avoids incurring any tax penalties for either the individual or the employer for not participating in an Affordable Care Act plan.

Preventive Minimum Essential Coverage is a layer of self-funded insurance that covers a list of over 60 preventive and wellness care services (these services are adjusted annually and additional services have been added for 2018). 

There are specific services for women, children, and all adults. The list of services includes yearly wellness checks, flu shots, vaccines, mammograms, colonoscopies, and many other preventive services (see the complete list at healthcare.gov.)

MANAGE: Health Savings Accounts For Tax Savings And Making It Easier To Obtain Discounts As A Self-Pay Patient


HSA's (Health Savings Accounts) are for the smaller bills associated with your health care needs (as well as for other medical services like dental and vision care, services that are either limited or excluded from sharing under the Membership Guidelines, or un-reimbursed costs for out-of-network preventive care ). Your HSA is a tax-advantaged savings account where you can contribute up to $3,450 (individual) or $6,850(family) for 2018 and take a tax deduction for the amount of your contribution. 

Individuals age 55 or over (limit of one per HSA) can also make additional "catch-up" contributions up to $1,000 per year.  Contributions are tax deductible. 

Funds in an HSA account can be used toward paying any qualified medical expense as defined by the IRS. Examples include prescription and some over-the-counter medications, doctors' visits, urgent care visits, glasses and vision care, and dental work.  Cosmetic-type services are excluded in most cases. Complete details of what are considered qualified medical expenses are contained in IRS Publication 502.

You reduce your expenses by the percentage of your tax bracket when you pay for a service from an HSA.  For example, if you're in a 32% federal tax bracket, you'll reduce your expenses for a qualifying medical expense by 32% when you pay for that expense from your HSA. In almost all states that have state income taxes you can also deduct the HSA contribution from your state taxes and additionally reduce your expenses by the % of your state tax bracket as well. 

Use this calculator to determine how much you can save by opening and utilitizing an HSA account. 

All members should establish HSA's to help pay for qualified medical expenses that are not Large Needs and to facilitate payment of their shareable medical expenses (see the description of Contain, below).



MITIGATE: Free Services To Save On Or Eliminate Medical And Outpatient Drug Costs

You can't Avoid, Prevent, or Manage all your medical costs. This tab contains information on free services you can use to eliminate or reduce the cost of medical services or outpatient drugs:

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.


Program membership includes access for up to 3 clinical hours of pastoral counseling per membership unit per membership year for items such as:









  • temperament therapy
  • marriage and family counseling 
  • pre-marital counseling 
  • extra-marital affairs 
  • resolving conflict
  • emotional crisis
  • depression
  • stress and anxiety
  • resolving trauma and abuse
  • grief, death and dying
  • codependency and family issues; and
  • spiritual  formation/direction  

These services are provided through Sedera Health but are not part of the medical cost-sharing tier of the strategy/program.. 

The program gives you access to the world's best doctors. Through the 2nd.MD program, top medical specialists are available to you. 2nd.MD's specialists are leading groundbreaking researchers and teach the most innovative techniques from the top medical institutions in the world, e.g. Mayo Clinic, Cleveland Clinic and Johns Hopkins. They're the "doctors' doctors."

If you face (1) a new diagnosis, (2) a possible surgery, (3) a change in medication, or (4) a chronic illness, even including one currently excluded from sharing because it's a pre-existing condition and want to discuss your options with a top expert on your condition, 2nd.MD is here for you. You’ll have access to more than 300 nationally recognized, board-certified medical specialists that cover more than 120 sub-specialties. These world-renowned physicians are available for consult via video conferencing or telephone from virtually anywhere in the world within about 3 days, providing program members the peace of mind that they want and deserve.

The program's experience with 2nd. MD is that 1/3 of planned surgeries are cancelled; that treatment plans are improved 73% of the time; and that the average savings/consultation are $3,000.

If a member receives treatment in accordance with the second opinion, his or her Initial Unshareable Amount for medical cost sharing (see the Contain section of this webpage) will be reduced by 50%

Sedera Health, the medical cost sharing administrator, requires members to use the 2nd.MD program prior to undergoing elective surgeries and suggests that members who have any of the four situations described three paragraphs above (including members with significant pre-existing conditions) utilize this no cost service.

If the member disagrees with the second opinion, s/he can request a third opinion at his or her own expense and the opinion of two of the three doctors will be considered the second opinion. 

Since treatment protocols and quality levels vary dramatically throughout the medical profession, Sedera requires members to utilize 2nd.MD prior to undergoing elective (non-emergency) surgeries.   Needs sharing may be reduced up to 25% on bills over $500 for members who either refuse to use the 2nd.MD Program, who intentionally skip the process, or who do not follow the second opinion.

TelaDoc™ (Telemedicine) offers convenient access to board-certified physicians, dermatologists, and pediatricians 24 hours a day 7 days a week/365 days a year through a phone call. It allows members to talk to a doctor when they need it, without having to book an appointment or take time off from work to visit an office in person. Members can call as often as they wish and there is no cost for a consultation. TelaDoc physicians can prescribe medications over the phone and can even video conference in most states. It’s not for everything, but great for the small stuff.  

Feeling ill is never convenient, especially in the middle of the night or while traveling.  With TelaDoc, the doctor is always in, day or night. 

Examples of items that fall into this category:  cold, sinus infection, and flu. 

Click here for the many reasons to use TelaDoc.

For emergencies call 911.  TelaDoc is not available in Arkansas.


World Meds is an international drug discount program that provides the most significant savings on brand name prescription drugs that we're aware of and also offers well-priced generic drugs. Through World Meds you can save up to 70% on some brand name medications. 

Members must provide a special code (which we will furnish upon membership) when calling to order medications.

This program is especially valuable for members who need brand-name or high-cost generic drugs, whether or not the cost of their medication is shareable under the program. In the case of a shareable medication, all members will benefit when a cost-conscious self-pay patient purchases a medication from World Meds for less than what he or she would normally pay.

Members who have established HSA's can save the equivalent of their tax rate (for example, if they have a 33% tax rate they'll save 33%) if they use their Health Savings Account to  pay for their unshareable medications. 


 

CONTAIN: Medical Cost Sharing For Large Medical Expenses

You can't Avoid, Prevent, Manage, or Mitigate all your medical costs.  You'll need to Contain the rest with medical cost-sharing.  Medical cost-sharing is a community of like-minded health-focused members banded together to share each other's medical costs above an amount they can comfortably afford.   

All services must be medically necessary.  Please consult the Membership Guidelines (most recently updated as of November 2017), and this listing of Frequently Asked Questions for specific details and limitations. You may also want to read the previously published Sharing Guide and Prospective Member FAQ for additional clarification, 

Both this illustration and this chart show how medical cost-sharing differs from insurance.  Part of the difference is that medical cost-sharing focuses on community and sharing of expenses rather than on shareholders and profit.  Another is that adminstrative expenses are considerably lower than for conventional health insurance plans.

Click on the following tabs to learn more about some of the major features and benefits of medical cost-sharing (read the Membership Guidelines for more details):

  • Accidents--  Any payments received by third party medical payors, who are expected to pay first, are first applied against the Initial Unshareable Amount 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 25 office visits and $3,000 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.  
  • 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 Initial Unshareable Amount 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 laboratory testing may be covered under the Preventive Care MEC.

  • Long-Term Care/ Skilled Nursing/ Visiting Nurses--When medically nececessary and/or whenever practical due to the severity, proximity and circumstances.  Nurse visits are shareable for up to 45 days following a hospitalization stay.
  • Maternity Care –Shareable maternity needs include expenses for prenatal care, delivery, postnatal care, miscarriage and congenital conditions.  There are special criteria for sharing needs of the child from genetic defects and hereditary diseases in accordance with Section 8.A. and the Appendix of the Select Membership Guidelines.  The member's IUA is waived for home births and vaginal birth after Caesarean (VBAC).
  • Medical Equipment Rental/Purchase --Medical equipment rental/purchase is shareable for the first month if prescribed by a licensed medical provider up to the maximimum 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 program 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 Initial Unshareable Amount threshold.
  • Physician Services--Surgeons, assistant surgeons, anesthesiologists, physicians' hospital visits, physicians' office visits, etc.
  • Therapies--Shareable for various therapies related to injuries or disease.  Subject to 35 outpatient sessions per need to a maximum of $3,500 per separate Need. (All types of therapies, e.g. speech, occupational, physical, respiratory, etc., are considered against the maximum.)
  • Therapeutic Massage Therapy--Shareable if prescribed by a licensed medical provider for up to 25 sessions to a maximum of $3,000 per separate Need. 

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

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

All shareable expenses must be part of a Need and are eligible for sharing ONLY after the Initial Unshareable Amount threshold is reached.        


     

 


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. 

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 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 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 or $1000) and request to be billed for any remaining charges.  Members are encouraged to contact their Member Advisor prior to making large up-front payments to medical providers.

Sedera reserves the right to reduce shareable expenses up to 25% off billed charges on bills of $500 or more in cases where a member refuses authorization to negotiate.

Paying the full-billed amount for medical services reduces the effectiveness of the self-pay patient approach and ultimately results in higher costs to the community.  Members should ALWAYS tell the provider they are self-pay patients and, as such, request a discount. Sedera reserves the right to reduce sharing by up to 25% per bill for members who repeatedly or habitually pay full-billed charges in advance.

Barring extraordinary circumstances, bills submitted more than 6 months from the date of service will not be shared.

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.). 

NOTE:  medical tourism (receiving treatment outside of the United States on a scheduled basis) can qualify as a shareable expense under the program.  Traditional health insurance covers overseas medical only in the case of a medical emergency, if at all.  Once you become a member, you can call the MyAHE Director of Member Services who will refer you to a Sedera Personal Member Advisor for more details.

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

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

Sedera is a total open access program which means there is no network (and no network limitations) in the healthsharing portion of the plan that is provided through Sedera.  You can utilize any provider who accepts cash payment. Sedera will reimburse you for shareable Needs in accordance with the Select Membership Guidelines. 

In order to facilitate provider acceptance and quick reimbursement 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.  

However, preventive and wellness care services under the MEC are provided under a PPO.

The MEC utliizes the PHCS network in all states except California (the Network By Design network is used in California).  These are large networks, and you must use a network provider for covered preventive services to be covered at no cost.  If a member does not obtain preventive and wellness services from a network provider, such services are considered out-of- network.  The member must pay the provider the full cost of the service and is reimbursed 130% of the Medicare Allowable rate for that service by the MEC provider.

You can go to www.multiplan.com and look for the PHCS  network listing which says "Specific Services Call to Confirm" to find PHCS providers and www.netbyd.com to find Network By Design doctors.  However, it's best to call 800-922-4362  or 209-229-8537 for PHCS and Network By Design respectively to check doctors, as these network listings change frequently and you want to make sure you use a network doctor for preventive or wellness care if you want to receive covered preventive and wellness services at no cost.

Remember that except for the MEC, Sedera (the health sharing portion of the program) is an open access program.

A condition is considered pre-existing if a member had symptoms or received treatment within the last 36 months prior to their membership effective date.  

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 $25,000 of expenses related to the medical condition are eligible for sharing, and up to $50,000 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 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 hemorrhoids
  • medical treatment for sleep apnea.
  • non insulin controlled diabetes

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


Enrollment in Sedera's health community (medical cost sharing) requires agreement to strive for a healthy lifestyle, no use of illegal narcotics, and no driving while intoxicated.

All prospective and currrent 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 Health is a benevolent organization, not an insurance entity.  I also understand that while Sedera assures that every effort will be made to make sure that members fulfill their monthly sharing commitment, Sedera in and of itself, can not guarantee payment of any medical expenses.

3.  I am a current employee, or eligible dependent of an employee of a participating employer group and am eligible for membership with Sedera through the employer relationship.

4.  I agree to practice good health measures and strive for a balanced lifestyle.

5.  I agree to refrain from the usage of any form of illegal substances.

6.  I agree to submit to mediation followed by subsequent binding arbitration, if needed, for any instance of a dispute with Sedera or its affiliates.

7.  I agree to sign and submit a membership continuation agreement each renewal year confirming my commitment to adhere to these principles.

Smokers pay a $45 monthly surcharge.  

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 disease, stroke, COPD, and cancer.  See the Select Membership Guidelines for more information.


Needs. 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 type in a membership year. Once an individual or membership type 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 Membership Guidelines. Experience is that the average family has only 1.8 Needs per membership year.

Limitations and Restrictions:  Most conditions are fully shareable in accordance with the Membership 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 Membership Guidelines for details. 

Some conditions which are usually totally excluded from sharing under individual health sharing programs are included in the list of restricted conditions. Examples include  ADD, ADHD and SPD treatment; alcohol or drug abuse treatment; medical equipment; nutritionists; vision therapy; orthotics; psychiatric care; and weight reduction. 

Prospective members should read and review the Membership Guidelines prior to enrolling the in program.

According to the Centers for Disease Control and Prevention, 86% of annual health care expenditures are for the treatment of chronic disease.  Chronic disease is responsible for 81% of all hospital admissions; 91% of filled prescriptions; and 76% of doctor visits.  A significant portion of these expenditures can be prevented, delayed or alleviated by eliminating three risk factors:  poor diet, inactivity and smoking.  This could result in the elimination of 80% of heart attacks and strokes; 80% of type 2 diabetes; and 40% of cancers. If, as expected, participation in Health Excellence Plus leads to the reduction of shareable medical expenses through preventive care and healthy living, monthly share contributions can be maintained or minimally increased. (Sedera Health, which administers the medical cost-sharing program, was actually able to DECREASE monthly share contributions in 2015.) In contrast, premiums for ACA plans that cover the 10 Minimum Essential Benefits have increased significantly since 2014.  

Analyses conducted in May 2017 by Sedera showed that members saved an average of 57% of medical costs just by being a member of the health sharing community.

Note:  Except for preventive care provided through the MEC, NO other portions/tiers of the program are insured and are therefore not regulated by state departments of insurance or consumer affairs or by the federal government.