FAQs for Brokers and Employers

General FAQs

A. The SB/A Core Health plans utilize the PHCS preferred provider network, one of the largest national networks of hospitals, clinics, and physicians in the USA. Out of Network providers are reimbursed at different levels of percentage of U&C or Medicare.

A. There are no waiting periods on all SB/A Core Health Plans Base Level benefit plans.  The Extra Enhanced Benefit provisions on Plans C, D, and E contain waiting periods for certain specific procedures listed in the brochure.

A. No. Coverage is subject to coinsurance up to the out-of-pocket maximum.

A. Dependent children are eligible up to their 26th birthday whether in or out of school. Common law marriages are allowed if certain requirements are met under individual state laws.  Married couples cannot split their enrollment into two enrollees.

A. SB/A CoOp sponsored health care plans are fully compliant and qualified with the Affordable Care Act and include the provisions of minimum essential coverage (MEC).

A. Employers are not required to contribute under the regulations of ERISA. However, the attraction and retention of talented and valuable employees should be evaluated when determining contribution amounts.

A. There are no waiting periods on basic level benefits or preventative care benefits. However, Extra Enhanced Inpatient/Outpatient benefits have a 90 day waiting period or 10 month waiting period depending on condition.

A. The SB/A Cooperative is a member-based organization that facilitates self-funded employer health care programs for its members. Employers and Broker Agents must join the SB/A CoOp and pay the annual fee.

A. Spouses are eligible. Dependent children are eligible up to their 26th birthday, whether in or out of school, and regardless of home of record.

A. Yes, but couples must meet certain requirements depending on your state’s specific requirements.

A. Yes, they will receive their own medical ID card with name, specific plan information, and national PPO network. The card will also include the membership customer service number as well as provider information similar to most medical ID cards.

SB/A Cooperative FAQs

A. The SB/A CoOp is a Non-Profit Agency Cooperative Corporation that does not buy or sell products or services, but acts as the legal Collective Agent of all the Cooperative Members to facilitate advantageous relationships for and between its members. The SB/A CoOp may legally aggregate small business employers together without becoming a Multiple Employer Welfare Association (MEWA) or acting as a Multiple Employer Trust (MET).

A. Employers pay $2.00 per month ($24 annually) for their SB/A CoOp membership.

A. The SB/A CoOp sponsors a self-funded medical employee benefits program that is fully compliant with ERISA. ERISA supersedes the Affordable Care Act and grants an employer the ability to offer non-conforming ACA medical benefits that are more affordable, providing the employer meets specific ERISA mandated requirements – in writing, funding, and non-discriminating in-benefit levels and eligibility. 

A. The SB/A CoOp sponsors its own SB/A Freedom Plan medical health benefit plans, and as an additional benefit, includes the ACA Minimum Essential Coverages as was required under the original Patient Protection and Affordable Care Act (ACA). This includes Routine Well Care, Adult Preventative Services and Screenings, Woman Preventative Services and Screenings, Child Preventative Services and Screenings, and 100% of ACA Mandated Prescriptions such as birth control.

A. Comprehensive health care plans include; zero deductibles, first dollar coverage, low out-of-pocket maximums, no pre-existing condition exclusions, no waiting periods for base plans, Affordable Care Act Preventative and Wellness (MEC – Minimum Essential Coverage) covered at 100%, pharmacy prescription, Virtual Clinic 24/7. Dental & vision discount plan may be included and are plan specific.

A. The base plans are called Plans A, B, C,  and D. As an everyday health care plan, employees will choose a plan with an annual coverage limit that meets their lifestyle and family needs.

A. Extra Enhanced Inpatient and Outpatient Benefit Provisions are plan specific. The Extra Enhanced Inpatient Hospital and Outpatient Surgery Benefit Provisions are  subject to a 6/12 pre-existing condition provision – conditions which exist 12 months before the effective date will be excluded from coverage the first 6 months of coverage; maternity inpatient hospital and outpatient services are effective 10 months after the effective date. Emergencies excluded from waiting period.

A. Major Medical plans combine the everyday health care plan with a catastrophic plan, and usually include a high deductible that must be met. The SB/A CoOp is a non-profit corporation. Annual coverage limits for different plan choices further reduce premiums for Employers and Employees. Enrollees in any plan realize immediate savings from no deductibles with 50/50 coinsurance with first dollar coverage.

A. An employer can include 1099 contractors in their group plan. The only requirement is to include their premiums in the “list billing” from the plan administrator. The employer is responsible for the aggregate list billing ACH invoice unless a W-2 or 1099 contractor has been removed from the monthly addition/termination report requirement sent to the plan administrator. Note: Failure to pay the ACH invoice will result in cancellation of the entire group plan.

A. The SB/A Freedom Plans utilize the PHCS network for the medical services. Our belief is that the best network is not the one with a 2% discount advantage; it is one that:

  • Offers extensive patient access to network providers
  • Offers competitive or lowest actual dollar pricing – not stated discounts
  • Excludes or minimizes contract language default pricing
  • Utilizes best in class providers based on treatment outcomes

Serve You Rx is the full-service Pharmacy Benefit Manager (PBM) and has a nationwide network of pharmacies that include major national and regional retail chains and independent pharmacies.

Provider Network & Plan Administrator

A. A Preferred Provider Network contains providers of various services and that are members of a specific network. Your medical benefits plan utilizes the PHCS network, one of the largest networks of providers in the USA. 

A. Most providers do belong to at least one network. The Gemini Healthcare Plus plan medical benefits plans are in the PHCS network.

A. No. The providers must be within the USA and its territories. 

A. Preferred Provider Organization contains providers of services such as hospital, emergency room, urgent care, physician, specialists, ambulance and lab tests.

A. Yes, SB/A CoOp provides a PPO provider lookup on your specific website home page or enrollment platform.

A. SB/A CoOp utilizes several pharmacy providers and are plan specific. Your plan administrator contracts with Serve You Rx which is a full-service Pharmacy Benefit Manager (PBM) with over 70,000+ pharmacies nationwide.

  • Value based low net cost formulary with trends below national rates
  • USA-based customer service representatives are available 24/7/365

A. SB/A CoOp utilizes several dental providers and are plan specific.

  • Careington Discount Dental is a nationally recognized dental network
  • 62,000+ participating dentists
  • Not insurance. Discount plans can be used continuously with no capped services
  • Save 20-60% on most dental services
  • Highly selective credentialing standards
  • Membership extends to all family members, throughout all 50 states

A. Free Market Administrators, LLC (FMA) is the plan administrator. FMA collects premiums, adjudicates claims and pays providers on behalf of the SB/A Cooperative’s employer members. Free Market Administrators was created with over 100 years of experience at the Senior Executive level. Partnering with the highest level pharmacy PBM and dental providers sets the highest performance and ethical standard for clients.

A. Once enrolled, clients receive a welcome package including instructions and medical ID cards. Enrollees can verify the provider is in the PHCS network (an actual emergency may preclude this), call for or go to the provider and show your medical ID card. Upon verification of enrollment and eligibility, care will be provided. Generally, there will be no payment at time of care (except for simple co-pay visit with proper CPT code provided by the provider). Claim is submitted by the provider to the plan administrator. Expect balancing payment instructions within 30 days.

For $20 co-pay visits, advise provider that the care required should be coded for the simple co-pay visit. Failure to discuss this will result in being billed at co-insurance rates, not co-pay rate.

For provider visits utilizing the Affordable Care Act – Minimum Essential Coverage provisions, again, advise the provider that the care desired should be coded properly to have it paid at 100%. Failure to code properly will result in the “base plan” zero deductible/1st dollar co-coverage provision to activate.

A. Occasionally, providers on some services may request a portion of your share of the co-insurance. In the remote event that a provider will not offer care, have them call the plan administrator with the phone number on the reverse side of the medical ID card. If the provider is in PHCS network and is uncomfortable without payment, you may pay the provider and file a claim.

A. Contact your plan administrator through the phone number on the back of your medical ID card. They will instruct you how to get reimbursed, or use those monies toward your coinsurance.

A. If questions arise prior to enrollment such as benefits, features, and exclusions, review the training tutorial and FAQ’s located in the main navigation bar on the website. If still looking for answers, please contact the SB/A CoOp staff through your agent.

After enrollment, if questions arise, contact the plan administrator customer service number on the reverse side of the medical ID card.

Plan Features & Provisions

A. The SB/A Freedom Plan series of health care benefit plans reside inside the Small Business Agency Cooperative non-profit corporation marketplace. The SB/A Freedom Plans have annual coverage limits. You purchase only the amount of care you might anticipate over the course of a year for you and your family. This creates considerable savings.

A. Clients evaluate the plans and select an annual coverage limit. The annual coverage limit represents the upper limit of care provided. Supplemental benefits or catastrophic plans may be acquired to increase coverage.

A. There are no waiting periods for base level benefits, however the “Extra Enhanced Benefits” (higher levels above base plan levels on Plan C $25,0000/$50,000) do have a waiting period.  The Extra Enhanced Inpatient Hospital and Outpatient Surgery Benefit is subject to a 6/12 pre-existing condition provision – conditions which exist 12 months before the effective date will be excluded for the first 6 months of coverage; maternity inpatient hospital and outpatient professional services are effective 10 months after the effective date.

A. There are no deductibles on Plans A, B, and C.

A. Yes and it’s available 24/7/365 with no charge. Members have access to State Board Certified Physicians who will be able to triage the patient and if required, prescribe appropriate medications to be purchased at a member pharmacy.

A. The medical benefit plans for employers may be enrolled anytime. However, your employer will set a specific time period for their open enrollment.

A. ERISA is designed for Employees and Employers. SB/A Freedom Plans are designed for business groups of 2+. Certain 1099 self-employed individuals may be able to access these health care plans when sponsored by an Employer. Note: all premiums are invoiced and paid by the employer or sponsor. 1099 contractor’s premiums must be collected by employer/sponsor prior to invoicing by plan administrator.

A. Spouses are eligible. Dependent children are eligible up to their 26th birthday, whether in or out of school, and regardless of home of record.

A. Yes, but couples must meet certain requirements depending on your state’s specific requirements.

A. Yes, they will receive their own medical ID card with name, specific plan information, and national PPO network name. The card will also include membership customer service phone number as well as plan administrator information.

A. Yes. The SB/A Freedom Plans are fully compliant with the Affordable Care Act and contain the minimum essential coverages (MEC). 

A. These medical benefit plans are available in all 50 states and territories.

A. Companies less than 50 employees are not required to contribute. However, employers should evaluate the contribution question as a component of retention and attraction of talented employees, plus contribution affordability.

A. There are no underwriting requirements.

A. There are no pre-existing condition exclusions for the base plans. However, the Extra Enhanced Benefits on Plan C contain a 12 month look back with a waiting period of 6 months for pre-existing conditions. 

A. All full-time and part-time employees working at least 16 hours per week per ERISA regulations.

A. Yes, the SB/A Freedom Plan series may be used in conjunction with all of the above, and with or without an existing HDHP. Certain requirements must be met to reside beside an existing high deductible health care plan.

ERISA FAQs

A. The Employee Retirement Income Security Act of 1974 is a Federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection to individuals In these plans.

A. ERISA products are regulated by the Federal Government and was established by Congress. The traditional insurance companies and their products are regulated by each of the 50 states through their individual departments of insurance.

ERISA sets the standards of conduct for those who manage an employee benefit plan and its assets (called fiduciaries). An ERISA-covered group health plan is an employment-based plan that provides coverage for medical care, including hospitalization, sickness, prescription drugs, vision, or dental.

A. The SB/A Freedom Plans are regulated under the Federal ERISA guidelines. These plans can be called health care plans or medical benefit plans.  Each of the 50 states has a separate insurance commission that regulates the major medical insurance plans. ERISA is restricted from using the “insurance plan” vernacular.

A. COBRA, HRA’s, HSA’s, FSA’s (flexible savings accounts), 401k Plans, Pension Plans, Dental Insurance Plans, Vision Insurance Plans, Cooperatives, EAP’s (Employee Assistance Plans), Life Insurance Plans, Prepaid Legal Service Plans.

Employer FAQs

A. No. Under ERISA, the federal government’s regulatory arm, ERISA-compliant medical benefit plans are only available through Employers and their Employees.

A. Cobra, HSA’s, HRA’s, Cooperatives, Retirement Plans.

A. The Employer must become a member of the Small Business Agency Cooperative. The SB/A CoOp is a marketplace for Employers to access the products that are regulated under ERISA.

A. Business owner members and brokers pay $2.00 per month ($24 annually) for their SB/A CoOp membership.

A. The ERISA regulated health care plans sponsored by the Small Business Agency Cooperative are similar to major medical plans but do have a significant difference. Major Medical plans generally incorporate the catastrophic component.  With the SB/A Freedom Plan series of everyday health care plans, the catastrophic component may be purchased separately. This allows for different lifestyles and economic variables to be controlled, purchasing the type of care programs you desire.

Pricing with a separate catastrophic plan could still yield significant savings.

A. The ERISA regulated medical benefit plans reside inside the SB/A CoOp marketplace. The SB/A Cooperative is a non-profit corporation which may result in significant savings. There are annual coverage limits that also contribute to significant savings. You choose the coverage that most fits your family and lifestyle.

A. The claims fund is a component of a premium and is used to pay providers for services rendered. The employer receives a portion of the unused claim fund back each year after a 12/18 runout. The employer is required to use those funds on behalf of the employees. The return of unused claims fund could increase contributions toward employee premiums as a reward for healthy lifestyles outside of work.

A. The Employer Sponsored ERISA Medical Benefit Plans are “owned” by the Employer when contracted. Under the rules of ERISA this self-funded plan claim fund is owned by the Employer. The Employer receives back the available unused claim fund after a 12/18 runout period (twelve months of enrollment service, followed by up to six months for adjudication of claims).

A. Each SB/A CoOp Employer Member has its own Employer Freedom Plan funded claim account maintained by the Plan Administrator. The Employer’s maximum claim liability is limited to the 12-month level funding of its claim account. The Member Employer owns the funds and will receive the unused available surplus following the 12/18 runout period (twelve months of enrollment service, followed by six months of adjudication of claims).

A. The SB/A Freedom Plan is an ERISA partially self-funded plan with fixed costs and claim account funding dollars. Stop-loss is a risk transfer contract that limits the liability (“stops the loss”) of the health care expenses for the Employer (plan sponsor).

A. Under ERISA regulations, the available unused claim fund surplus is returned to the Employer for use toward the benefit of the Employees. Most Employers will return it into the contribution pool year after year, reducing the expenditure of contribution from the company funding accounts.

Depending upon the use or non-use of the claims fund to pay providers could result in a significant surplus.

A. The Employer realizes flexible design to meet your company’s needs; low participation requirements; minimum two W2’s (includes employer); no contribution requirements under 50 employees; return of unused claim fund; list billing; and Section 125 Cafeteria plan.

The Employee experiences low premiums; zero deductibles; 1st dollar coverage; co-insurance discounts from first dollar spent; first three simple visits for $20; comprehensive health care benefits including hospital/ER/urgent care/specialists/medical & surgical/maternity/ambulance/behavioral health/chiropractic; prescription pharmacy; dental & vision discount plan.

A. Hospitals, physicians, medical device manufacturers, pharmacy PBM’s, and many other providers of service create a list detailing the official rate charged an individual for procedures/services/goods. The Preferred Provider Organization (PPO’s) will negotiate discounts or reduced pricing off the chargemaster. The Plan Administrator will generally audit invoicing for accuracy and acceptability.

A. ERISA specifies information that must be included in the Summary Plan Description (SPD). The SPD must accurately reflect the contents of the plans. The SPD is an important document that informs the participants what the plan provides and how it operates.

It provides the information on when an employee can begin to participate in the plan. It also explains how the service and benefits are calculated, when benefits become vested, when and in what form the benefits are paid, and how to file a claim for benefits. If a plan is changed, participants must be informed, either through a Summary of Material Modification (SMM), or a revised Summary Plan Description. This must be distributed free of charge.

A. The claims fund is a component of a premium and is used to pay providers for services rendered. The employer receives a portion of the unused claim fund each year after 12 months of service, followed by completion of the 6 months adjudication process. The employer is required to use those funds on behalf of the employees. The return of unused claim funds may be used toward contributions, bonuses, or other benefits for the employees.

A. Only W-2 employees that participated in the SB/A Freedom Plan health care plans are eligible for the unused claims fund benefit provided by the employer. Employer return of unused claims fund may not be used for the benefit of 1099 contractors under current ERISA regulations.

A. Immediate family members cannot use the W-2 as a way to create a “2 or more” employee group. However, it is okay if the employer has other non-family related employee W-2’s.

A. With certain restrictions, the employer may have multiple health care plans and insurance policies in place. When adding the SB/A health care plan, the open enrollment period in existence must be honored.

A. An employer can include 1099 contractors in their group plan. The only requirement is to include their premiums in the “list billing” from the plan administrator. The employer is responsible for the aggregate list billing ACH invoice unless a W-2 or 1099 contractor has been removed from the monthly addition/termination report requirement sent to the plan administrator. Note: Failure to pay the ACH invoice will result in cancellation of the entire group plan.