NCBA Frequently Asked Questions

Overview of the National Consumer Benefits Association (NCBA)

Why is the National Consumer Benefits Association (NCBA) able to offer healthcare plans to their members? 

On June 19, 2018, the U.S. Department of Labor expanded access to affordable health coverage options for America's small businesses and their employees through Association Health Plans.

Association Health Plans work by allowing small businesses, including self-employed workers, to band together by geography or industry to obtain healthcare coverage as if they were a single large employer.

See: Presidential Executive Order Promoting Healthcare Choice and Competition Across the United States:

https://www.whitehouse.gov/presidential-actions/presidential-executive-…

 

What is the healthcare offering by the NCBA, and who is it available to?

The National Consumer Benefit Association (i.e. “NCBA) healthcare offering is made up of 2 different components that can provide a complete healthcare coverage plan, as well as, additional optional benefits. The member has the ability to pair (“choose”) the benefits that best fit their healthcare needs and budget. A member must purchase an Apex plan before they can add on additional services from Sedera.  The initial Apex Purchase includes your membership in the NCBA.

The total offering includes:

Component 1:   Apex Management Group Plans:

  • HDHP/Basic MEC and an HSA Compatible plan, or
  • Apex Advantage Plan

Component 2:  SederaHealth Medical Cost Sharing

These plans are available through the NCBA to:

  • Self Employed and 1099 individuals
  • Small Groups

By “Pairing” what do you mean?  How can they be combined?

A member can choose a number of product combinations (“pairing”) to meet their needs:

  • An Apex product only
  • Apex and Sedera

For plans that are on the NCBA platform who is actually the Plan Sponsor, the Employer or the NCBA?

Under ERISA, the group plan would be sponsored by the Association (NCBA) not the Employer.  The NCBA has an Association Adoption Agreement for Employers.

The Employer can choose to offer the plan to “Full Time Employees” or “Full Time and Part Time Employees”

Employer Membership Fee and Payment – The employer (the business) will pay a monthly fee if $19.95 for NCBA membership, which gives their employees access to NCBA membership and benefits. This monthly membership fee is an ACH payment directly from the employers designated checking or savings account.

 Where is the NCBA Located?

The National Consumer Benefits Association (NCBA)

16476 Wild Horse Creek Road

Chesterfield, MO  63017

1 (800) 992-8044

National Enrollment Center:  (800) 242-6263

Component 1 - Apex Management Group offering (NCBA)

What is another term for Apex plans?

Apex plans are also referred to as - Limited Coverage Plans.

If they are MEC plans, or limited coverage, just what do they take care of?

They cover a lot!  Apex plans provide the day to day foundation of healthcare services for the NCBA plan.  Which is why they are a mandatory purchase within the NCBA healthcare offering.

Apex Advantage Plan will account for 90% of the normal healthcare services needed by a member.  These include - Preventative Care, Primary Office Visits, Specialist Office Visits, Urgent Care Visits, Lab Services, Imaging or X-Ray Services, and Prescription Drugs.

The Apex HDHP/Basic MEC when combined with a health saving account also provides a great solution to address healthcare needs and lowering cost.  With this plan a NCBA member can:

  • Lower monthly health insurance premiums
  • Money put into your HSA is not taxed
  • You earn tax-free interest on HSA balances
  • HSA funds used for qualified medical expenses are not taxed

Are there any additional out of pocket cost for Preventative the Preventative Benefits?

No.  100 % Coverage is provided on the Apex plans. No Copay for Mandated Preventative Services on both plans.

Can you tell me more about the Advantage Plan 6 Tier Drug benefit?

The Advantage Plan provides a 6 tier prescription drug benefit with an emphasis on Generic Medications. Tier 1: Low Cost Generic is only a $1 Copay. Tier 2: Generics, 10% coinsurance. Our Pharmacy Benefit Manager, WelldyneRx has a substantial discount off of the retail level, often 50% or more. As an example, if a Generic medication was $60 retail cost, WelldyneRx often has a discount of 50% or more. So the $60 Prescription could be reduced to $30 and your coinsurance for that Generic medication would be $3.00 There are also benefits for Brand and Non-Preferred Brand medications as well as limited coverage for Specialty Drugs.

What other benefits does the Apex "NCBA offering" include?

Apex Management Group’s NCBA offering also includes Teledoc.

Teledoc provides access to a doctor 24 hours a day, 365 days a year, by web, phone, or mobile app.  You can also select a time that’s best for you by choosing “schedule” instead of “as soon as possible.”

Teledoc leads the market with the industry’s most comprehensive suite of telehealth services.  Toy can receive convenient quality care from a variety of licensed health professionals. If medically necessary, a prescription will be sent to the pharmacy of your choice.

We make it that easy!

Are there any plan exclusions that I need to know about?

3D MRI’s are not covered. Enhanced imaging services, the use of contrast material to enhance the MRI or CT Scan is not a covered service. 

If a member does have a 3D MRI, the base cost of an MRI or CT Scan would be covered and applied to the enhanced imaging procedure.  The member would then be responsible for the balance between the base MTR cost and the 3D MRI (enhanced procedure cost).

Component 2 – SederaHealth – Medical Cost Sharing

What kind of company is Sedera Health?

Sedera is a patient advocacy and benevolence organization. Sedera provides the framework and administrative support for our group Medical Cost Sharing Membership, as well as access to a number of ancillary health services.

If a NCBA member chooses the Sedera medical cost sharing plan within the NCBA offering, just what are they financially responsible for?

The NCBA member who also chooses a SederaHealth has responsibility for 2 payment buckets -

  1. MONTHY CONTRIBUTIONS - A Sedera “member” makes a monthly contribution amount. (i.e. -  a payment)
  2. INITIAL UNSHARABLE AMOUNTS (IUA) - For each “Need” an “Initial Unsharable Amount” (IUA) is paid by the member. When establishing their plan a member can select IUA amounts of ​​​​ - 
  • $500
  • $1,000
  • $1,500
  • $2,500
  • $5,000

Anything over the IUA amount is fully sharable with the community.  The IUA a member selects for their plan effects a member’s monthly contribution (i.e. - payment) amount. 

What is Medical Cost Sharing?

Medical Cost Sharing is NOT Health Insurance.

There no insurance or re-insurance involved.  Forget about terms like high deductibles, pre-authorization, network, and unaffordable premiums.  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. Sedera is not licensed or registered by any insurance board or department since we are not practicing the business of insurance.  Sedera does not assess an 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 other 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.

Sedera believes many of the current problems with the health care system are the direct result of restricting 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.

Does Sedera’s medical cost sharing program (on a standalone basis) comply with the Affordable Care Act requirements?

Sedera’s medical cost sharing program is not a substitute for insurance as defined by the ACA.  But there is a solution.

To deal with the requirements of the ACA, Member companies that have a Sedera plan typically pair (“combine”) a qualifying self-insurance plan like the ones offered Apex Management Group (which includes Minimum Essential Coverage) administered by a licensed third-party administrator (aka "TPA"). 

Apex Managment Groups self-insurance plans are designed to take care of preventative care needs, and can also provide a lot more.  For example, when a Sedera is paired with the Apex Advantage Plan a member would be covered for Primary Care Visits, Urgent Care, Diagnostic X-Ray and Lab, and CT Scans or MRI’s (Note: 3-D MRI’s are not covered).  The Apex Plans will cover up to 90% of a members usual day-to-day healthcare requirements, and can greatly reduce annual out of pocket expense.

 

So what does SederaHealth cover?

Sedera Medical Cost sharing is designed to cover a “need”.  A need can be illnesses or injuries resulting in visits to licensed medical providers, emergency rooms, diagnostic testing facilities, laboratory fees or hospitals are shared on a per person, per incident basis.  Go to sedera.com See Sections 6-9 of the Sedera Member Guidelines for details.

What is the process for paying medical bills when an individual need occurs?

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 professional team of medical bill negotiators (The Karis Group) are available to negotiate on behalf of members to reduce medical bills.  These skilled negotiators serve as trusted member advocates, expertly spotting things like hidden or duplicate fees, incorrect quantities and more.  Bills are typically reduced to an average discount of 53% or more.

A final negotiated amount is agreed upon – a final shared payment amount is sent to the Sedera member.  The member then pays the bill directly.   The member ultimately has financial responsibility – this is another reason why Sedera is not insurance.

Simply put, it just a different way to pay medical bills.

How long does it take Sedera to process a sharing amount (i.e. a payment) to a member for a submitted medical need?

The sharing turnaround time ranges from 15-60 days from receipt of your bills and required information depending whether negotiation is required or not. If the Need Processing Form is correct and complete, and there are no ongoing financial negotiations with providers, a need will normally be shared the second Wednesday after Sedera receives it.

Are there any specific medical conditions that have an exclusion or waiting period?

The 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.

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.

If a person does have a pre-existing condition and they do become a member of Sedera how are Pre-existing Conditions looked at from a payment standpoint?

Many times, Medical Cost Sharing, which is a solution to the high cost of insurance plans delivers savings of 50% or more, at the same time providing a more comprehensive plan with lower out-of-pocket costs.  It is, however, NOT FOR EVERYONE.  Pre-existing conditions will have limitations on the benefits paid for specific time periods.

  • Year 1 - No coverage is provided
  • Year 2 -$15,000 in pre-existing coverage
  • Year 3 - $30,000 in pre-existing coverage
  • Year 4 – pre-existing condition is fully shared

Are there any Pre-Existing conditions that Sedera will allow?

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.

Also, when well controlled, there would be no restrictions on

  • High Cholestoral
  • Sleep Apnea
  • Non-Insulan Dependent Diabetes.

Medical Cost Sharing is a new concept for my clients.  Does Sedera provide a high level of Client Service?

Yes, there are a number of levels of client service provided by Sedera.

  • “Teledoc” uses telephone and videoconferencing to provide on demand medical care
  • Access to Nation’s Top Doctors through “2nd MD”
  • Counseling Services

A medical Advisor coach that will help with -

  • Medical Record Transfer
  • Physician and Hospital Search
  • Appointment Scheduling
  • Prescription Cost Search
  • Elder Care Services
  • Surgery Cost Saver
  • Pre-Negotiation

Under the Sedera plan does the member and/or family member who is going into the hospital for some health related event have to declare they are self-payers?

Yes, they should declare they are self-pay at admission or time of service.  They can address their Initial Unsharable Amount (IUA) and advise that the bills are to be sent directly to them.

What happens when a provider requires payment up front for services?

Members are encouraged to use their HSA funds (if applicable) to provide payment for qualified medical services and equipment. If a Member does not have a HSA or does not have adequate HSA funds available, they may be required to pay out-of-pocket. 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. Very often Sedera pre-pays 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.

 Will Sedera share medical costs (needs) that were incurred outside of the United States?

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 other kinds of services are provided under the Sedera offering?

In addition to medical expenses, Sedera provides access to valuable counseling, Medical Bill Navigation, Telemedicine ("Teledoc"), Expert Second Opinion, and Personal Member Advisor Services to all members.

How does Sedera do all this?

By layering various healthcare services, Sedera enables individuals and families access to high quality healthcare that is affordable and flexible.  Members may use any doctor/hospital/or facility they want.

Can my Sedera Membership be dropped if they have very high medical needs?

Members cannot be dropped from this 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.

Are there any Limits on the number of “Needs” a person has with the SederaHealth plan?

SederaHealth annual out of pocket expenses are limited to:

  • 3 needs* per Individual (over 3 100% covered)
  • 5 needs* per family (over 5 100% covered)

* if a “need” incident carries over for treatment into a following year(s) and any additional expenses are incurred, they are still fully shared as the initial IUA that was already paid by the member. 

This is a differentiating factor from traditional health insurance (which Sedera is not).  With traditional health insurance, a “new deductible” would start at the beginning of a new year, even if a treatment is for the same “need”. 

General FAQ's Regarding Member Issues

How are NCBA Member enrollments and plan administration handled?

Administration 123 – Laguna Beach, CA will coordinate On-Line enrollment and Agent compensation. The Third Party Administrator for the plans will be HMA (Hawaii Mainland Administrators).

How do NCBA Members obtain info on their membership benefits?

Members will receive a membership booklet along with an ID card in the mail. They can also go online to the NCBA website; www.ncbamembers.com, register, then login in and you can access your benefits. If you have additional questions, you can call the toll-free number that is in in your member booklet, on your ID card, or online.

For Group Plans, who is actually the Plan Sponsor, the Employer or the NCBA?

Under ERISA, the group plan would be sponsored by the Association (NCBA) not the Employer.  The NCBA has an Association Adoption Agreement for Employers.

The Employer can choose to offer the plan to “Full Time Employees” or “Full Time and Part Time Employees”

Employer Membership Fee – The employer (the business) will pay a monthly fee if $19.95 for NCBA membership, which gives their employees access to NCBA membership and benefits.  Employees also pay this fee, but the fee is embedded in their monthly healthcare payment.

Does the NCBA healthcare offering have a network of of Physicians?

There are two answers to this question. 

 

Component 1 - has the PHCS Physician Network

Component 1 of the NCBA offering (Apex Management Group products) provides members access to one of the largest Physician Networks in the country.  Preferred HealthCare Systems (PHCS) has over 900,000 physicians nationwide.  Apex Plans are designed to address a members day-to-day health care needs such as Preventative Care, Primary Care, Specialists, Urgent Care, Laboratory, Imaging and Prescription Drugs. By frequency this accounts for almost 90% of healthcare service provided.  The Apex Advantage Plan provides great benefits with small co-payments and 100% coverage for those services.

Component 2  - allows freedom of choice for more serious needs

Component 2 of the NCBA offering  (SederaHealth Medical Cost Sharing) addresses the more serious health care "needs" of a member (i.e. - a surgery, prolonged treatments for a chronic illness, serious accidents).   When utilizing the SederaHealth component of the NCBA offering, members are free to choose who, and where, to receive treatment for more serous health care needs.   

General FAQ's Regarding Agent Contracting

What does an Agent need to provide to start contracting with the NCBA?

In addition to standard contracting information your will need to provide the following:

  • A copy of your Sedera Certificate of Achievement (Sedera Certification)
  • A copy of your State Insurance Producers License (this is needed because Transamerica products are insurance products)
  • Proof of E&O Coverage

What is Sedera Certification process all about?

Individuals who are offering the Sedera Medical Cost Sharing  to their clients either directly or through a platform like the NCBA are REQUIRED to be “Sedera Certified”

The whole certification process requires a person to take an Online course that requires only about 2 hours of time to complete.  The course gives a complete overview of the Sedera Medical Cost Sharing product and how it works. There is brief test at the end of each section. Sedera requires this certification process to ensure individuals are representing the offering, as well as, the “terms” describing the offering correctly.

Agents who want to sell Sedera should address this immediately.

With 2 different product components, is the contracting difficult for the Agent?

It is a breeze!

This single NCBA contract covers both product offerings (Apex and Sedera) when you are offering them through the NCBA platform.  The process is easy as you only have to go to through source.

Use the following contracting link to sign up and start doing business.

NCBA Contracting Link:    https://www.1enrollment.com/agents/signup.cfm?id=314464 

The PASSWORD for contracting is “Launch”: