USAHP FREEDOM Plan. Plans A, B, & C with Minimum Essential Coverage (MEC) SERVICE FLEXIBILITY INTEGRITY

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1 An Affordable ACA Qualified & ERISA Health Plan Solution USAHP FREEDOM Plan Plans A, B, & C with Minimum Essential Coverage (MEC) Sponsored by: USA Health Plans & SBA Cooperative Administered by: Free Market Administrators.com SERVICE FLEXIBILITY INTEGRITY Maximizing savings and providing cutting edge solutions to help you effectively manage your health care costs.

2 USA HEALTH PLANS USA Health Plans offers a suite of solutions that provide both the agent and consumer affordable and unique healthcare offerings that address many of today s challenges in the healthcare industry. Through USA Health Plans and our strategic partnerships, we are able to develop and deliver health benefit offerings that are not only unique to the industry but also exclusive to USA Health Plans. The SBA Coop is as 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 contractual relationships for and between the members. The SBA Coop may legally aggregate small employers together without becoming a Multiple Employer Welfare Association (MEWA) or acting as a Multiple Employer Trust (MET). The SBA Coop will sponsor the unique ERISA Supplemental Health Care Plans that are ACA qualified when offered in tandem with a High Deductible Health Plan (HDHP) or a Minimum Essential Coverage (MEC) Plan. 2

3 The SBA Cooperative USAHP FREEDOM Plan "An ERISA Health Plan Solution Efficiency Savings Simplicity Freedom The SBA Coop was formed in 2017 as a Non Profit AGENCY Cooperative Corporation to provide for Employer/Employee health care benefits in the small and large Group Employer marketplace. Each group employer Coop Member can sponsor a Partially Self Funded ERISA Employer Welfare Benefit Plan for the benefit of its Employees and their Dependents. Called the USAHP FREEDOM Plan, it is an ERISA health plan for sponsoring employers offered in conjunction with a Minimal Essential Coverage (MEC) Plan. The employer s claim exposure is protected via an Aggregate Stop Loss Fund (ASLF) owned by the SBA Coop Employer Members. Each SBA Coop Employer Member has its own the USAHP FREEDOM Plan funded claim account administered by RCI, Inc., 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 available surplus following the Plan Year runout at the end of the 18th month Incurred in 12 months and paid in 18 months (12/18). Association plans of self employed members will receive any surplus prorated on a calendar year on a 12/18 basis. Available surpluses are paid at the end of the 18th month. Today s health benefits landscape is more challenging for employers to navigate than ever before. Yet, there s a reason why nearly 70% of employees who have health coverage in the U.S. are now enrolled in some sort of self funded plan and why that number is growing they work. It s that simple. Companies of all sizes and types, including public entities, are finding this to be true as they make the switch from the more limited fully insured plans to the added flexibility and customizable health benefit options self funding offers. We offer 4 plan options which are illustrated in this document. To participate and take advantage of the USAHP FREEDOM Plan options, the following is required: Broker and Employers must join the SBA Coop complete the SBA Coop Membership Agreement and pay the annual $24 membership fee Broker completes SBA Coop Compensation Form, Broker W 9, and Broker Information Form this is a onetime requirement Employer completes the Group Information Form and Group W 9 Employees complete the USAHP FREEDOM plan Employee Enrollment Form for larger employer groups, Employers can submit an electronic eligibility spreadsheet Go to to download forms and learn more. 3

4 USAHP Freedom Plans (In Network Provider (PPO) Only) Freedom A Freedom B Freedom C Preventative Care (MEC) (Including Adult, Women, Child Preventative Services Screenings & Services ) Covered 100% Covered 100% Covered 100% 24 Hour Virtual Clinic (On line & Telephonic Doctor Calls) Covered 100% No Copayment Unlimited Covered 100% No Copayment Unlimited Covered 100% No Copayment Unlimited Primary Care Office Visits (3 per year) (Additional visits apply to Deductible / Co Insurance) $20 Copay Per Visit (3 Visits Per Year) $20 Copay Per Visit (3 Visits Per Year) $20 Copay Per Visit (3 Visits Per Year) Plan Annual Deductible None None None Co insurance Percentage Covered 100% Preventative items 50% Co ins on 1st $7,500 (No Tier 2) 100% Preventative items 50% Co ins on 1st $10,000 (No Tier 2) 100% Preventative items 50% Co ins on 1st $10,000 (Tier 2 ) 100% of Next $25,000 Prescription Pharmacy Benefit, Inpatient / Outpatient Hospital & professional Services. (Includes all ACA mandated Benefits) 50% Co ins on 1st $7,500 50% Co ins on 1st $10,000 50% Co ins on 1st $10,000 Tier 2 Benefits Inpatient (Medical & Surgical) & Outpatient (Surgical only) x x 100% of next $25,000 (Not all ACA mandates Apply, see guidelines for details) Annual Maximum of Covered Services Individual / Family $7,500/$15,000 Individual / Family $20,000/$40,000 Individual / Family $45,000/$90,000 Minimum Essential Coverage (MEC) Routine Well Care As Provided Under the Affordable Care Act (ACA) Member Annual Out of Pocket Maximum on Covered Services 2018 Individual $7,000 4 / Family $14,000 Call

5 The Employer FREEDOM Plan Cost Funding Freedom Plan Rates Freedom A Freedom B Freedom C Employee Only = $ $ $ Employee + Dependents = $ $ $

6 Minimum Essential Coverage (MEC) Annual Benefit MEC Covered Services Minimum Essential Coverage (MEC Plan) In Network Provider (PPO) Only Annual Deductible None Member Annual Out of Pocket Maximum None Co insurance Percentage covered (Plan Pays Based on Contracted Amounts) 100% Preventative Care Covered at 100% Pharmacy Benefit Annual Maximum of Covered Services 100% of ACA mandated prescriptions, i.e. Birth Control No Annual Maximum Routine Well Care As Provided Under the Affordable Care Act (ACA) Adult Preventative Services Screenings & Services Listed Below are Eligible 1. Abdominal Aortic Aneurysm 9. Diet Counseling Covered at 100% 2. Alcohol Misuse 10. Obesity Covered at 100% 3. Aspirin 11. Sexually Transmitted Infection (STI) Covered at 100% 4. Blood Pressure 12. Syphilis Covered at 100% 5. Cholesterol 13. HIV Covered at 100% 6. Colorectal Cancer 14. Tobacco Use Covered at 100% 7. Depression 15. Immunization Vaccines Covered at 100% 8. Type 2 Diabetes Covered at 100% Woman Preventative Services Screenings & Services Listed Below are Eligible 1. Anemia 12. Gestational Diabetes Covered at 100% 2. Bacteriuria Urinary Tract 13. Gonorrhea Covered at 100% 3. BRCA 14. Hepatitis B Covered at 100% 4. Breast Cancer Mammography 15. Human Immunodeficiency Virus (HIV) Covered at 100% 5. Breast Cancer Chemoprevention 16. Human Papillomavirus (HPV) DNA Test Covered at 100% 6. Breastfeeding 17. Osteoporosis Covered at 100% 7. Cervical Cancer 18. Rh Incompatibility Covered at 100% 8. Chlamydia Infection 19. Tobacco Use Covered at 100% 9. Contraception 20. Sexually Transmitted Infections (STI) Covered at 100% 10. Domestic and interpersonal Violence 21. Syphilis Covered at 100% 11. Folic Acid Supplements 22. Well Woman Visits Covered at 100% Child Preventative Services Screenings & Services Listed Below are Eligible 1. Alcohol and Drug Use 14. Hematocrit or Hemoglobin Covered at 100% 2. Autism 15. Hemoglobinopathies or Sickle Cell Covered at 100% 3. Behavioral 16. HIV Covered at 100% 4. Blood Pressure 17. Immunization Vaccines Covered at 100% 5. Cervical Dysplasia 18. Iron Supplements Covered at 100% 6. Congenital Hypothyroidism 19. Lead Exposure Covered at 100% 7. Depression 20. Medical History Covered at 100% 8. Developmental 21. Obesity Covered at 100% 9. Dyslipidemia 22. Oral Health Covered at 100% 10. Fluoride Supplements 23. Phenylketonuria (PKU) Covered at 100% 11. Gonorrhea 24. Sexually Transmitted Infection Covered at 100% 12. Hearing 25. Tuberculin Testing Covered at 100% 13. Height, Weight and Body Mass Index 26. Vision Covered at 100% 6

7 Plan Provisions and Exclusions USAHP FREEDOM Plans covers: ACA Preventative Care, Routine Checkups, Pap Smears, Flu Shots, Immunizations, and More Primary Care, Specialist, & Urgent Care Visits Plus X rays, CT & MRI Scans, Lab & Diagnostic Services (3 office visit copays limited to internal medicine, Family Practice, Pediatrician, & OBGYN office and other Outpa tient Services (CPT ) Prescription Drugs ACA at 100% (includes Birth Control) plus all others at indicated copays or indicated coinsurance up to threshold limit using the Rx pharmacy card at your favorite pharmacy Telemedicine (24 Hour Virtual Clinic) Inpatient Psych/Substance Abuse benefits limited to 30 days per year Plan pays Co Insurance based on contracted amounts Pharmacy benefits are eligible for Rx discounts above base plan threshold All other medical services are eligible for PPO network discounts for services above the stated annual maxi mum threshold Additional Exclusions from coverage: Workers Compensation injuries and illness Cosmetic surgery procedures exceptions to some reconstructive surgeries Bariatric/Gastric Sleeve surgery Sex transformation/change surgery Items Below Only Apply to Tier 2 Inpatient & Outpatient Benefits Enhanced benefits in addition to base benefits Inpatient Psych/Substance Abuse benefits limited to 30 days per year Additional Inpatient Annual Maximum benefit is limited to stated annual maximum Inpatient Hospitalization and Professional Services for Surgical & Medical Services plus Outpatient Surgical (only) Services Emergency Room/Urgent Care, Lab, X ray and Imaging (if admitted) Ambulance Service (if admitted) Additional Inpatient & Outpatient Benefit provision is effective 60 days after the effective date for surgical services and 10 months for maternity for the member Any hospital confinement that began on or before the effective date is excluded from plan coverage Outpatient Drugs, Kidney Dialysis, Chemo Therapy, and All Other Infusion Therapy is excluded from coverage under Inpatient & Outpatient Provision 7