My journey with healthcare cost sharing began back in 2008. This is when I became very reactive to the health insurance industry. I had moved to Boulder, CO and started working for a high-end dental practice. We required our patients to pay for their services in cash. If they had insurance, we would file it for them and the patient would receive the reimbursement. We were considered “out of network”. A title that comes with several challenges.
I remember services such as oral cancer screenings and perio therapy being extremely difficult, if not impossible to get covered. It didn’t make sense that insurance companies would not cover things that would actually “help” our patients. In many cases, these preventative services assured their diagnoses wouldn’t get worse. Even back then insurance companies were in between the doctor and the patient and definitely did not have the patients’ best interests in mind.
This infuriated me. As a person who believes things should be fair and equal in all aspects of life, I asked myself, “How can these insurance companies pretend to have your back when in reality their actions showed something entirely different?” Thus began my long journey of disbelief and shock at the US health insurance market.
It continued when we moved back to Austin, TX where I became the office manager of a well-known, local food company. I was responsible for facilitating our health insurance enrollment. For two years I sat silent while I watched our premiums significantly rise. We would jump from one plan to another searching for less expensive options for our team. Our premiums kept going up while our coverage kept going down. Higher deductibles and out of pocket maximums meant any type of treatment or procedure was not obtainable for most of our employees. Some team members couldn’t even afford to be on the plan in the first place.
By 2016 I’d had enough. We found and signed on for a plan that claimed to allow three doctors office visits, outside of the wellness visits, that were 100% covered. This could be an appointment with a general physician or a specialist. That year I went to the dermatologist and was shocked to receive a bill stating that I owed 100% of the visit’s cost.
Over the years I’d become familiar with insurance jargon and I knew I could figure this out if I put my mind to it. Not to mention, I come from a long line of people who get sh%t done, so I called United Healthcare right away. After being placed on hold and transferred from this rep to the next I explained my case and OH! They now see in my plan that I do have 3 visits per year that are to be covered 100%. They would resubmit the claim back through and it would be processed correctly. I was skeptical, but assuming positive intent I let this one slide as an honest mistake.
I saw a doctor two more times during that calendar year which should have been processed as one of these three covered visits. Neither of the visits was processed correctly. On my last call to United Healthcare I gave careful feedback to the representative about my experience. She stated that she sees claims processed incorrectly very frequently. I couldn’t believe it! I could feel rage build up inside me and my “unfair flag” started waving high in the air.
I understood my insurance plan, which let’s be honest, few people do, so I knew to call in when I knew something should be covered that wasn’t. But how many people don’t remember their plan or get their bills in the mail and just assume the claim was processed correctly and their procedure wasn’t covered? I see now that insurance companies count on our ignorance. They bank on the fact that a large percentage of people are going to conveniently forget about the coverage they have.
Fairness. How are these billion dollar insurance companies allowed to break the fairness rule and why do we keep giving them our money? I didn’t want to anymore. I was out. 2017 rolled around and we saw 15-21% increases in price on our team members’ re-enrollment plans. I started doing the math and in 3-4 years, the premiums were going to be the entire paycheck of some of our team. How were they going to get the care they need? We were all feeling the unsustainable squeeze of rising costs. I took it upon myself to look outside the box that year.
I started by asking my peers about their insurance. One of my close friends told me about a Direct Primary Care (DPC) system that she was a part of. She loved the doctor and the services he provided. Membership was simple. She paid a monthly fee and in return she could see the doctor as much as she needed with no wait. She could also text, send photos or even video chat. This was a game changer for a busy stay-at-home mom with a young child and new baby. She raved about the quality of care that the doctor provided her family.
Discovering medical cost-sharing
So I sought out this doctor. My employer’s intention was to have our team healthy and working, right? What if we could join this doctor’s plan as a company? Were group rates available? Well, let’s just say this doctor lived up to his reputation. He called me back and we spoke in depth about healthcare costs, his DPC option, other groups he works with, and some other options he recommended that I should explore. He specifically mentioned Sedera medical cost sharing. I had never heard of medical cost sharing before, but was very curious to learn more. The next step was to reach out to Sedera and find out what it was all about.
Luke was the first person I spoke with from Sedera. He gave me a quick rundown of how it all works. Medical cost sharing is a group of people who come together to share each others’ medical costs when they become unaffordable. Originally ministry based, this successful model has been around for over thirty years with a proven track record. Sedera broke the mold when they took out the faith-based component. They don’t require customers to sign a statement of faith to become a member, they believe everyone should be able to benefit from this approach. After our call, Luke ended up coming out to our office to share more about how this actually works. He sold me on this example:
This is the CEO of Sedera’s real-life story. His family had a high-deductible insurance plan. His middle son was plagued by ear infections which required him to receive multiple prescriptions, in-office injections, a specialist visit and finally, a surgery to place ear tubes. With the regular insurance model, he was responsible for paying all the costs totaling $2525 because he still hadn’t reached his son’s $5000 deductible. With Sedera, he would have been required to pay $500 of the costs. Sedera has what they call an Initial Unshareable Amount (IUA); this is the amount a member is required to pay before sharing begins on their need. A “need” is one or more medical expenses caused by a SINGLE event. Luke went on to describe that these visits happened in the Autumn and we all know what happens in the new year: our deductibles are reset. Happy New Year y’all!! Well his poor son’s ear tubes fell out and they had to have the surgery all over again after their deductible had been reset. This meant the family was now out over $5000 for the same “need”. If they would have been with Sedera during this time the total they would have paid is $500, as this was still considered the same need.
Medical cost sharing in real life
Sedera views medical costs in three tiers. The first tier is services which are covered by a MEC (minimum essential coverage) plan. This plan fulfills your individual mandate to become ACA compliant. All of your preventative services are covered by this plan such as your wellness visits, annuals, vaccinations, mammogram and colonoscopy. The second tier is your small-to-medium visits like sinus infections, UTI’s, sick visits, etc. Anything under the amount of your IUA. Some MEC’s allow you to have a HSA which you and your employer can contribute pre-tax dollars into to pay for medical services. These funds are ideal to pay for these medium medical costs. The third tier is the large needs such as delivering a baby, a cancer diagnosis, or surgery. That is where Sedera comes in. Once you meet your IUA, the costs are shared with the other members in the community. Sedera offers various IUAs that members may select from based on their household needs. The higher the IUA the lower the monthly cost.
Back at my local food company, the team was intrigued by this affordable option. We were seeing savings in between 30-50% from our medical insurance quotes. We decided to bring this in as an option for our renewal. Since I was the office manager and had an above average understanding of insurance, I became the Sedera educator for our team. Always communicating when it was the proper time to use Sedera for a medical cost or to use one of the built in services that comes with a Sedera membership such as Teledoc or 2nd MD.
When I finally had to use medical cost sharing
The true test came when one of us ended up having a need to be shared with the community and guess who that person was…me! I had been in communication with Sedera as I became pregnant with our second son that year. We were planning to deliver at a local birth center here in Austin. They required me to pay in full prior to delivery, so I had to share a need with the community. My needs processor was so compassionate and connecting. She always used my name instead of an ID number like I had so often been reduced to over the years with big insurance companies. She asked for the birth center’s client agreement including costs for Sedera to review. After sending it over she responded that this particular type of cost wasn’t eligible for bill negotiation so the entire cost was shared with the community the next week. My IUA was deducted from the invoice total and I received a check in the mail within 2 weeks which I deposited and then paid the birth center. It was that easy. I just paid my IUA for the birth of my baby. I really couldn’t believe it.
When my birth plan became more complex, my experience with Sedera only improved. Despite the best-of-laid plans, I ended up having our baby by emergency cesarean-section. It was a traumatic experience and we are lucky our son is here with us today. Our visit to the hospital resulted in a 10 day stay in the NICU. I emailed Bridget, my needs processor while in the hospital and she was again, so compassionate and connecting stating first that she was glad we were all ok. I was asked to start sending the invoices to her as they came in the mail and they were going to be negotiated down by the Karis Group who is a patient advocacy group and also Sedera’s parent company. Since I had already paid my IUA and this was the same need, all of my costs such as hospital, surgery, anesthesiologist, medications, doctor fees, etc. were shared with the community. My son’s own need was started and we were responsible for paying his IUA before his costs were shared with the community.
Bills came in over the next two months and I shared them with Bridget. She would share them with the Karis Group. They were negotiated down and then the costs were shared with the community and I would receive a check and then I would pay the provider. It took some pro-action on my part to stay organized throughout the process, but I was happy to do this. I was a contributing part of this community and my costs were being paid for by the contributions of others. Additionally, since my delivery didn’t happen at the birth center I received a reimbursement from them which I then forwarded back to Sedera to be available for other needs. It was all a communal effort and I was so happy to do my part.
Throughout this stressful birth experience, Sedera was there for me 100%. I completely see first-hand how this model works and I never want to give health insurance my hard earned dollars again. I became such an advocate for Sedera that I ended up switching careers and now work for them! Spreading the word on medical cost sharing and helping others see there is a better option truly inspires me. I encourage any employer groups who are struggling to provide their employees with an affordable option that will help them in times of emergency to reach out to Sedera. It was a huge game changer in my life and I believe it could be in yours as well.
Have you ever had experience with cost-sharing insurance or Sedera?