DEFINED TERMS

Annual Limit

The maximum amount shared for Eligible Needs per participating Member.

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.

Benevolence Organization

An organization whose primary purpose is to care for the needs of the persons/members who make up the membership. A Benevolence 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.

Contribution List

Members can join 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 20, who are the Head of Household’s dependent by birth, legal adoption, or marriage, who is participating under the same combined membership. Unmarried children ages 20 through 26 years of age may participate in the membership as a dependent if they are a full-time student or a full-time service volunteer.

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 reimbursement by community funds via the contributions of Zion Health Members.

Group Membership

Two or more family members participating under the same membership.

Head of Household

The oldest participating Member in the household.

Health Care 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 these 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 Membership 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 completed once a Member becomes pregnant and is submitted by the Member to Zion Health within 30 days of confirmation of pregnancy from a Licensed Medical Professional.

Maximum Shareable Amount

Certain medical conditions have a maximum dollar amount (limit) that can be shared for any one need as described in the guidelines. This maximum amount is referred to in each such instance as the Maximum Shareable Amount.

Medically Necessary

A service, procedure, or medication necessary to restore or maintain physical function 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 Membership 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 these Membership Guidelines and membership type.

Membership

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

Membership Cancellation Request

A form submitted by a Member to Zion Health requesting that their membership be cancelled. The form must include the reason for cancellation and the requested month in which the cancellation of the membership is to be effective. The form must be received by the 15th day of the month for the cancellation to apply to the following month or any future requested month. Cancellations become effective on the 1st day of the requested month following the timely receipt by Zion Health of the Membership Cancellation Request Form.

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 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.

Membership Plan

A variety of sharing options are available with different Member Initial Unshareable Amounts, Member Responsibility 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 used in the Benevolent Fund administered by Zion Health and disbursed according to the eligible needs of its Members in accordance with these Guidelines.

Need Eligibility Manual

Reference materials that comprehensive information on requirements, policies, and procedures, and its intended to help Zion Health or any third-party resource to accurately determine, identify, and verify eligible or Ineligible Needs. The contents of these materials are for Zion Health internal use only.

Need Request

A request that is required to process medical needs for accidents, injuries or medical conditions that result in a visit to the emergency room or other medical need. Members must notify Zion Health within 30 days of discharge. Need requests can be submitted at ZionHealth.org or by calling Zion Health.  The Needs Request must be submitted to Zion Health within 3 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 and would be part of a need that meets all qualifications. Qualifications 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.

Pre-Existing Condition

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. Symptoms can include but are not limited to the following: abnormal discharge or bleeding; abnormal growth; break; cut or tear; discoloration; deformity; full or partial loss of use; obvious damage, illness or abnormality; impaired breathing; impaired motion; inflammation or swelling; itching; numbness; pain that interferes with normal use; unexplained or unplanned weight gain or loss exceeding 20% of the total body weight occurring within a six-month period; fainting, loss of consciousness, or seizure; or abnormal results from a test administered by a medical provider. Needs that result from a Pre-existing condition that existed prior to a Member’s Effective Date (known or producing observable symptoms) are only shareable if the condition appears to be fully cured and 12 months have passed without any symptoms (either benign or deleterious), treatment, or medication, even if the cause of the symptoms is unknown or misdiagnosed.

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.

Sharing Summary

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 Giving

Voluntary contributions by Members for the purpose of offsetting expenses for other Members’ Special Needs.

Special Needs

Medical needs that do not fall within the definition of Eligible Needs but are not a violation of the Member requirements; e.g., a prior medical condition.

UCR (“Usual, Customary, And Reasonable Costs”)

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 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 these Guidelines.

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