DEFINED TERMS

Additional giving

Voluntary contributions by members for the purpose of offsetting expenses for other members’ special needs.

Annual limit

The maximum amount shared for eligible needs per participating member per year. Zion Health does not have annual or lifetime sharing limits for our members unless specifically stated in the Membership Guidelines.

Application date

The date Zion Health receives a complete membership application.

Benevolent organization

An organization whose primary purpose is to care for the needs of the persons/members who make up the membership. A benevolent organization is not an insurance company.

Benevolent fund

A fund maintained by Zion Health created from the contributions of members for the exclusive purpose of reimbursing eligible needs of members in accordance with the Additional Giving guidelines.

Condition Existing Prior to Membership

Any illness or accident for which a person has been diagnosed, received medical treatment, been examined, taken medication, or had symptoms for 24 months prior to the effective date. For information on sharing for pre-existing conditions, see the section of the Member Guidelines titled “Conditions Existing Prior to Membership.”

Congenital Condition

Any disease or physical abnormality present at birth or that is identified or diagnosed within the first year of life

Contribution list

A list of members who are being billed by payroll deduction through a company opposed in lieu of direct billing from Zion Health.

Date of service

The day medical services were rendered on behalf of a participating member.

Dependent

The head of household’s spouse or unmarried child(ren) under the age of 26, who are the head of household’s dependent by birth, legal adoption, or marriage, and who are participating under the same combined membership. Unmarried children under 26 years of age may participate in the membership as a dependent.

Effective date

The date a person’s membership begins. Zion Health Direct members also have the effective date as the billing due date.

Eligible need

A medical need that qualifies for sharing via the contributions of Zion Health members.

Head of household

The oldest participating member in the household.

Household membership

One or more family members participating under the same membership.

Healthcare sharing

A membership-based, non-insurance arrangement established for the purpose of sharing legitimate healthcare expenses between members.

Inactive member

A contributor, and contributor’s dependents if applicable, who has/have not submitted monthly contributions in the manner established by the Member Guidelines. An inactive member is not eligible for sharing.

Ineligible need

A need disqualified from voluntary sharing of contributions from member contributions due to a policy set forth in the Member Guidelines.

Initial Unshareable Amount

The specified financial amount that members are required to bear on their own prior to any amount that may be eligible for sharing.

Licensed medical professional

An individual who has successfully completed a prescribed program of study in a variety of health fields and who has obtained a license or certificate indicating his or her competence to practice in that field (MD, DO, ND, NP, PT, PA, Chiropractor etc.)

Lifetime limit

The maximum amount shared for eligible needs over the course of an individual member’s lifetime of membership.

Maternity need

A need request that must be submitted once a member becomes pregnant within 30 days of confirmation of pregnancy from a licensed medical professional.

Maximum shareable amount

The maximum dollar amount (limit) that can be shared for any one need. Certain medical needs have a maximum shareable amount as described in the Guidelines.

Medically necessary

A service, procedure, or medication necessary to restore or maintain physical function and that is provided in the most cost-effective setting consistent with the member’s condition. The fact that a provider may prescribe, administer, or recommend services or care does not make it medically necessary. This applies even if it is not listed as a membership limitation, or an in
the Member Guidelines. To help determine medical necessity, Zion Health may request medical records and information from licensed medical professionals.

Member(s)

A person or people (or dependent thereof) who has agreed in writing to abide by the requirements of Zion Health and is thereby eligible to participate in the sharing of medical needs with other members in accordance with the Member Guidelines and membership type.

Membership

This term applies to the collective body of all active, participating members of Zion Health.

Membership cancellation request

A request by a member to Zion Health that their membership be canceled. The request must include the reason for cancellation and the requested month in which the cancellation of the membership is to be effective. Zion Health requires 15 day notice prior to your payment draft date. Zion Health does not prorate cancellations or gift refunds. Cancellations become effective on the last day of your monthly billing anniversary following the timely receipt by Zion Health of your membership cancellation request.

Members have 30 days from the membership cancellation date to reactivate membership in order to qualify for continuous membership. For example, employers who terminate employee memberships.

Membership commitment

The required principles and ongoing behavioral code attested to by members as required for membership.

Member responsibility amounts

Amounts needed to be paid by the member for medical costs that are not sharable with the Zion Health community.

Membership update

A communication from the member to Zion Health providing any changes to the details of their membership information (i.e. change of address, phone number, etc.) or requesting that their membership be changed. The change request or update may take up to three business days to complete. Once a representative of Zion Health approves the requested changes, the approved changes may go into effect on the monthly membership anniversary.

Membership limitation

A specified medical condition for which medical needs arising from or associated with the condition are ineligible for reimbursement from the Benevolent Fund. An associated condition is one that is caused directly and primarily by the medical condition that is specifically ineligible. The membership limitation will be issued during the application process and may be subject to medical record review. Membership limitations (excluding cancer) do not apply to office visits/urgent care.

Member plan

A variety of sharing options are available with different initial unshareable amounts and sharing limits, as selected in writing on the membership application or enrollment portal and approved by Zion Health.

Membership withdrawal

When a membership has been or will be cancelled due to the submission of a Membership Cancellation Request Form, a violation of the Zion Health’s Principles of Membership, or non-receipt of a voluntary monthly contribution or annual membership fee for more than 10 days past the date such payment was due. Such cancellation of membership is referred to as membership withdrawal.

Monthly contributions

Monetary contributions given voluntarily and placed in the care of Zion Health by a member to maintain active membership and to be disbursed for to the eligible needs of its members in accordance with the Member Guidelines.

Needs request

A request that is required to process medical needs for accidents, injuries, or medical conditions that result in medical costs. Need requests can be submitted at zionhealth.org or by calling Zion Health. The needs request must be submitted to Zion Health within six (6) months of the need to be eligible for sharing.

Non-affiliated provider

A non-network, licensed medical professional or facility as determined by Zion Health.

Office visit

Sick visits, wellness visits, specialists, and urgent care are generally considered to be office visits. The medical bill must include an office visit CPT code for the need to qualify as an office visit. Qualifications for sharing eligibility include exclusion of prior medical conditions and meeting your initial unshareable amount (IUA).

Plan administration

A collaborative process of planning, evaluating, facilitating, coordinating, and advocating for options and services to meet a participating Member’s Eligible Needs through available resources to promote quality, cost-effective results.

Proration

If shareable needs are ever significantly greater than shares available in any given month, Zion Health may prorate the needs amount requested for medical expenses. This involves an across the board percentage reduction of needs payments but does not necessarily mean that all member needs will not be met in that month.

Shareable amount

The amount of the need request that remains after the member’s initial unshareable amount has been satisfied and falls within the guidelines for sharing within the membership.

Explanation of sharing (EOS)

Correspondence that is delivered to the participating members and their providers once medical needs have been processed, are pending, or have been rejected. The Sharing Summary will state their member responsibility amount as well as any amounts shared by the Benevolent Fund on the member’s behalf.

Special needs

Medical needs that do not fall within the definition of eligible needs but are not a violation of the member requirements and may be eligible for Additional Giving; e.g., a prior medical condition.

Unusual, customary, and reasonable costs (UCR)

The general cost of medical services in a geographic area, as determined by Zion Health, based on what providers in the area usually charge for the same or a similar medical service.

Unshareable amount(s)

A medical expense incurred by a member that is not shareable for one or more of the following reasons: a member’s violation of the Zion Health’s Principles of Membership, non-current membership status, or any other condition or requirement that is excluded by the Member Guidelines.

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