FAQs
A. An independent Affiliate acts as an Employer group of one, within the compliance guidelines of ERISA self-funding. Independent Affiliate must:
- Become a Member of the Small Business Agency Cooperative, Inc.
- Sign Independent Affiliate work agreement.
- Complete a W9 for 1099 contractors.
- Complete Employee Enrollment Application with health care plan selection.
- CompleteACH for TPA auto-debit.
A. Features and Benefits are generally the same for Independent Affiliates. This special program is for Affiliates as individual 1099 Contractors. Employer groups of 10+ have access to the higher level catastrophic coverages.
A. There is no underwriting.
A. Yes. Without underwriting and potentially high premiums and deductibles, the control mechanism consists of annual coverage limits on base plans. High monthly care needs may necessitate accessing a fully-insured high deductible insurance plan or accessing the State Exchanges.
A. Independent Affiliates can access enrollment and membership agreements though a different website URL. www.sbacaffiliate.com
A. The TPA will build a file in 10-14 days. You will receive a welcome sleeve of information and medical ID card.
A. Loomis Co., your Contract Administrator, issues all Employee Members medical ID cards with all contact and required information. Your Physician, clinic or hospital Provider calls the Network Provider listed for eligibility using the member ID card information you provide.
If you are choosing to utilize your $20.00 co-payment benefit, remember to mention the co-payment for limited services at your provider.
For Pharmacy point of sale, provide your member ID card to pharmacist as you would any other pharmacy coverage ID card. For 90 day mail order prescription, contact pharmacy benefit manager (you must be enrolled for this service) directly by phone or computer.
For Affordable Care Act (ACA) preventative and wellness benefit coverage, mention this to your provider for proper CPT coding. Failure to do so may result in your invoice submission reflecting a “subject to coinsurance” calculation.
Always verify that your provider is in the PHCS PPO Network.
A. The SB/A CoOp uses PHCS Preferred Provider Network, one of the largest network of Hospitals, Clinics, and Physicians in the USA. SB/A CoOp Core Health Employer Group Health Plans are designed for use as an in-network PPO only. Exceptions include being away from your local region Providers, out-of-State or emergencies.
A. The SB/A Core Health Plans are ACA qualified and exceed the essential health benefits required by Health & Human Services (HHS).
The Summary of coverage Brochure lists all the features and benefits.
Included in all health care plans are;
Telehealth: 24/7/365 Virtual Clinic allows you to reach a US licensed board certified physician.
- Physicians will triage the patient, diagnose, and offer a personalized treatment plan
- Physicians can prescribe medications which can be purchased at a member pharmacy
The SB/A Freedom Protect Plan utilizes ProCare Rx for prescription and pharmacy needs.
- ServeYou Rx is a full-service Pharmacy Benefit Manager (PBM)
- Over 70,000+ pharmacies in the national network
The SB/A Freedom Protect Plan utilizes the DentaMax Dental and Vision Plan.
DenteMax is one of the most recognized professional dental networks in the nation. DentaMax works with 62,000+ participating dentists.
A. Loomis Co., your TPA and Contract Administrator, is a respected 40 year national Third Party Administrator. Loomis is committed to creating value for their broad client base of both fully insured major medical and self-funded clients. Loomis Co. continues to be a critical measure and has maintained the highest performance standards within the industry. Loomis Co. remains focused on not only exceeding the highest ethical standards in the industry, but upholds the utmost integrity for our clients, and has redefined the way clients look at the world of health care benefits.
Invoices from Provider Physicians, Clinics, and Hospitals are adjudicated, claims paid, explanation of benefits submitted to client members. In addition,
A. The SB/A Core Health Plans reside inside the Small Business Agency Cooperative non-profit corporation. The plans belong to the Employers and are designed without profit. The plan design contains “Annual Coverage Limit” caps. The cost-sharing (coinsurance) amount replenishes each anniversary. You choose and purchase the coinsurance amount based on your anticipated needs. Contractual discounts in excess of Annual Maximum Coinsurance limits continue to be available as patient pay.
A. “Annual Coverage Limit” caps the cost-sharing (coinsurance) amount and replenishes each anniversary. You choose and purchase the coinsurance amount based on your anticipated needs. Your coverage and health care plan remains in force throughout the year and PPO discounting and other contractual discounts remain available.
A. There are no waiting periods on basic level benefits or preventive care benefits. However, extra enhanced inpatient/outpatient benefits have a 60 day waiting period or 10 month waiting period for maternity. Waiting periods on extended catastrophic benefits for pre-existing conditions are detailed in the Summary of Coverage brochure.
Base plans have no waiting periods.
A. There are no front-end deductibles.
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.
A. If you have questions about any features, benefits, and exclusions prior to enrolling, please review the Frequently Asked Questions. You may also link and view video information. If reviewed and still looking for answers, please call the SB/A CoOp Representatives at (888) 857-2667.
Note: Once enrolled, please call the Contract Administrator. The Customer Service number located on your medical ID card.
A. An iGenius Member acquiring a Smart finance package may Enroll as an iGenius Affiliate.
A. Spouses are eligible. Dependent children are eligible up to their 26th birthday, whether in or out of school, and regardless of whether they reside at home or not.
A. Yes, but they must meet certain requirements depending upon your specific state laws. Domestic partnerships are not approved.
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 a large catastrophic component. With the SB/A Employer Group Plan series of everyday health care plans. Individuals who may need higher catastrophic or critical illness limits can contact licensed Agents for those needs. 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. 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.
Generally a Summary of Coverage is distributed as a brochure or booklet.
A. Yes, members will have access to TelaDoc Health which allows members to call and speak to State Board Certified Physicians who will be able to triage the patient and if required, prescribe appropriate medications to be picked up at a member pharmacy.
A. DenteMax Dental has been serving the dental community for over 20 years and committed to making quality care more accessible and more affordable. DentaMax offers discount dental plans with no annual limits on use. Vision discount plans are also available.
A. Major Medical plans combine the everyday health care plan with a catastrophic plan, and usually include a high premium plus a high deductible that must be met. The SB/A CoOp is a non-profit cooperative corporation which reduces premiums, and the plans have annual coverage limits or “caps,” which further reduce the premiums. SB/A CoOp Employer group health and wellness plans (SB/A Core Health) offer zero deductibles with first dollar 50/50 coinsurance.
A. The SB/A CoOp sponsors the SB/A Core Health and Freedom ICON medical health benefit plans, and as an additional benefit, each 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. 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.
