Coverage - During Special Election Periold

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SBA MEC Healthcare Plan: Comprehensive Overview and Benefit Synthesis

Executive Summary

The SB/A MEC Plan is an ACA-qualified and ERISA-compliant health plan solution designed to provide affordable Minimum Essential Coverage (MEC). Facilitated by the SB/A Cooperative and administered by The Loomis Company, the plan offers a tiered benefit structure (Plans 1, 2, and 3) that prioritizes preventative care with no deductibles, no waiting periods, and guaranteed issue.

Critical takeaways include:

• Compliance and Structure: The plan is a partially self-funded ERISA arrangement leveraging an Aggregate Stop Loss Fund (ASLF) to limit employer liability.

• Preventative Focus: All plans cover 100% of ACA-mandated preventative services through the First Health Network.

• Tiered Value Additions: Higher-tier plans integrate $0 copay laboratory services through QuestSelect and fixed-fee primary/urgent care via HealthCare2U (HC2U).

• Operational Requirements: Use of primary and urgent care benefits (Plan 3) requires a "Telemed First" triage protocol.

• Geographic Availability: Coverage is available in 40 states and the District of Columbia.

  
  

Organizational Framework and Partnerships

The SB/A MEC Plan is supported by a network of specialized entities that manage administration, legal agency, and benefit delivery.

Entity	Role
SB/A Cooperative	A non-profit "Agency" Cooperative Corporation acting as the legal collective agent for members to facilitate contractual relationships and sponsor ERISA plans.
The Loomis Company	The Third Party Administrator (TPA) responsible for billing, claims processing, enrollment, and regulatory compliance.
USA Health Plans	The designated Plan Distributor.
Serve You Rx	The Pharmacy Benefit Manager (PBM) providing a nationwide network of over 66,000 pharmacies and managing prescription costs.
First Health Network	The Preferred Provider Organization (PPO) network utilized specifically for preventative services.

The Cooperative Model

Formed in 2017, the SB/A CoOp allows small and large business employers to aggregate and protect claim exposure through an Aggregate Stop Loss Fund (ASLF). This level-funded model limits an employer’s maximum claim liability to 12 months of funding. Member employers own the fund and may receive defined surpluses on a calendar basis.

Plan Tiers and Monthly Rates

The program offers three distinct plans to accommodate varying levels of care needs and budget requirements.

Benefit Feature	Plan 1	Plan 2	Plan 3
MEC Preventative Services	100% Covered	100% Covered	100% Covered
ACA Mandated Rx	100% Covered	100% Covered	100% Covered
Telemedicine	N/A	N/A	Unlimited ($0 Fee)
QuestSelect Labs	N/A	$0 Copay	$0 Copay
Primary Care (HC2U)	N/A	N/A	$35 Copay
Urgent Care (HC2U)	N/A	N/A	$75 Copay

Monthly Premium Rates:

• Member Only: $99 (Plan 1) | $119 (Plan 2) | $149 (Plan 3)

• Member + Spouse: $135 | $165 | $209

• Member + Child(ren): $125 | $159 | $219

• Member + Family: $159 | $209 | $275

Note: An optional RX Valet Copay Card can be added for $9.95 to $15.95 per month depending on coverage tier.

Detailed Benefit Analysis

Minimum Essential Coverage (MEC)

All plans provide 100% coverage for routine well-care as mandated by the Affordable Care Act, provided they are accessed through In-Network (First Health) providers.

• No Deductible/Out-of-Pocket Max: There are no annual deductibles or member out-of-pocket maximums for these services.

• Covered Screenings: Includes a comprehensive list of services for adults (e.g., blood pressure, cholesterol, Type 2 diabetes), women (e.g., mammography, cervical cancer, prenatal screenings), and children (e.g., autism, immunizations, vision).

QuestSelect Laboratory Benefit (Plans 2 and 3)

This is a subscription-based program (not insurance) providing $0 copay for over 1,200 outpatient diagnostic labs.

• Inclusions: Blood work, urine testing, cytology, pathology, and cultures.

• Exclusions: Testing during hospitalization, STAT/emergency labs, time-sensitive esoteric testing (fertility, bone marrow), and non-laboratory imaging (X-rays, MRIs).

• Protocol: Members must present their QuestSelect card and ensure the physician sends the specimen to Quest Diagnostics.

HealthCare2U (HC2U) Services (Plan 3 Only)

HC2U provides primary care and urgent care benefits through a proprietary network separate from First Health.

• Telemed First Protocol: A virtual triage is mandatory before an in-person visit can occur. Telemedicine then directs the member to an available in-network physician or urgent care facility.

• Chronic Disease Management: Includes management for 13 of the most common chronic states, potentially reducing the need for specialist visits.

• Pediatric Limitations: In-office pediatric visits are not included for children ages 0-2. Urgent care and telemedicine for this age group may be limited if a pediatric specialist is required.

Pharmacy Benefits

• Standard MEC: 100% coverage for ACA-mandated prescriptions (e.g., birth control).

• Serve You Rx PBM: Provides access to over 66,000 pharmacies and specialty mail-order services.

• Optional RX Valet Card: A separate copay drug card available for all plan tiers to help manage non-mandated drug costs.

Geographic Availability

The plan is available in the majority of U.S. states, with specific exclusions based on regional regulations.

Status	States
Available	AL, AR, AZ, CA, CO, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, NC, NE, NH, NJ, NV, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI
Not Available	AK, CT, MT, NM, NY, ND, RI, SD, VT, WV, WY

Enrollment Requirements

To participate in the SB/A MEC Plan, three administrative steps are required:

1. Broker Appointment: The broker must complete an appointment with USA Health Plans.

2. Employer Membership: Employers must complete the Group Enrollment Form and join the SB/A CoOp.

3. Individual Application: Enrollees must complete a Group Health Application. Notably, there are no medical questions or pre-existing condition limitations.