Sedera Health Frequently Asked Questions

Pairing Apex and Sedera– A Complete Combination

Why is SederaHealth being offered on the Apex Management Group website?  Are they  part of Apex management Group?

SederaHealth is a separate organization from Apex management Group.  SederaHealth is, however, a partner organization to Apex Management Group and their healthcare services compliment our own Apex suite of products very well.

Apex products, when paired ("combined") with SederaHealth Medical Cost Sharing can provide a very comprehensive group plan solution at a cost savings of 50% or more than a conventional group health insurance plan.  In this era of out-of-control health insurance cost, we believe a sponsor of a group plan should examine and consider this "paired" solution of Apex/Sedera as a viable alternative.  

Does SederaHealth medical cost sharing (on a standalone basis) comply with the Affordable Care Act requirements?

Sedera’s medical cost sharing program (on a Standalone basis) 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 typically pair (“combine”) qualifying self-insurance plan like the ones offered Apex Management Group  (which includes Minimum Essential Coverage) administered by a licensed third-party administrator, or TPA. 

Apex Management Groups self-insurance plans are designed to take care of preventative care needs, and can also provide a lot more.  For example, when paired with the Apex Advantage Plan a member would have access Primary Care Visits, Urgent Care, Diagnostic X-Ray and Lab, and CT Scans or MRI’s*, all with a small co-pay.  (*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. 

When Member companies participate in Sedera’s Medical Cost Sharing Membership, their employees will have access to the assistance of many other Members in handling the costs of medical incidents that exceed their Initial Unshareable Amount (IUA). 

Overview of Sedera Health Solution

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.

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.

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.

General FAQ's Regarding Sedera Solution

When a person becomes a member of SederaHealth, just what are they financially responsible for?

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

  • MONTHY CONTRIBUTIONS - A Sedera “member” makes a monthly contribution amount. (i.e. -  a payment)
  • INITIAL UNSHARABLE AMOUNTS (IUA) - For each “Need” an “Initial Unsharable Amount” (IUA) of ($500, $1,000, $1,500, $2,500), or $5,000 – depending on you plan) – anything over that fully sharable with the community.  The IUA a member selects for their plan effects a member’s monthly contribution (i.e. - payment) amount. 

Does SederaHealth medical cost sharing (on a standalone basis) comply with the Affordable Care Act requirements?

Sedera’s medical cost sharing program (on a Standalone basis) 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 typically pair (“combine”) qualifying self-insurance plan like the ones offered Apex Management Group  (which includes Minimum Essential Coverage) administered by a licensed third-party administrator, or TPA. 

Apex Management Groups self-insurance plans are designed to take care of preventative care needs, and can also provide a lot more.  For example, when paired with the Apex Advantage Plan a member would have access Primary Care Visits, Urgent Care, Diagnostic X-Ray and Lab, and CT Scans or MRI’s*, all with a small co-pay.  (*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. 

When Member companies participate in Sedera’s Medical Cost Sharing Membership, their employees will have access to the assistance of many other Members in handling the costs of medical incidents that exceed their Initial Unshareable Amount (IUA). 

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.

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.

How does the Health Saving Account (HAS) work with the HDHP/100% Preventative Plan when Paired with Sedera Health?

The HSA compatibility is just for the Apex HDHP/Basic MEC..  The plan was designed to provide the Framework to make it HSA compatible. The HDHP portion of this plan is a $3,000 Ind / $6,000 Fam deductible, 80% thereafter and max out-of-pocket of $6,650 Ind / $13,300 for family.   This is the HSA Framework.  There are only three items that would track to satisfy the deductible, that is Primary Care, Urgent Care and Lab services.  It of course is not intended to be a traditional HDHP that is comprehensive and catastrophic in nature. A large need would go to Sedera. 

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, Expert Second Opinion, and Personal Member Advisor Services to all members.

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”. 

Sedera Certification and Contracting

How do I contract with Sedera to begin selling their product?

Individuals who are offering the Sedera Medical Cost Sharing to their clients need 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.

To begin the Sedera certification process go to:  https://sedera.com/affiliate-registration/