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HEALTHSHARE MEMBER

GUIDELINES

At Zion HealthShare, we have reimagined the HealthShare model to simplify the experience for our members and make medical cost sharing more accessible. Our Member Guidelines outline who we are as an organization and how we share in the medical costs of our members.

Member Guidelines

HEALTHSHARE BEGINNINGS

Modern-day medical cost sharing communities, also known as HealthShares, began in the 1980s when a beloved pastor in Ohio was involved in a terrible automobile accident. His congregation came together to pay his medical bills—in full, in just forty-five days. This same community decided to continue following the biblical mandate to “bear one another’s burdens” by sharing healthcare costs in a simple yet practical way.

Members of HealthShare communities across the country share one another’s medical expenses in a similar fashion. This system has proven to be an effective alternative to traditional—increasingly complex and costly—health insurance. Members enjoy the freedom, flexibility, and stability of community medical cost sharing while keeping more money in their own pockets.

Zion HealthShare began sharing medical costs with its members in 2019 and has since become the fastest-growing, top-rated HealthShare in the nation. Learning from the organizations that came before it, Zion HealthShare was founded with the mission to reimagine the medical cost sharing model to fit the needs of its members amid the rapidly changing environment of American healthcare.

OUR MISSION

Zion HealthShare offers superior-quality service to its community. Our goal is to continually reimagine the HealthShare experience as a member-focused community. Zion HealthShare is a community that employees are proud to be a part of, that medical professionals prefer for their patients, and that members love and recommend to their family and friends.

PRINCIPLES OF MEMBERSHIP

Each member of Zion HealthShare must comply with the following requirements to maintain membership with Zion HealthShare and remain eligible to participate in the medical cost sharing program. Adherence to the Zion HealthShare Principles of Membership minimizes medical risks, encourages good health practices, and ensures member integrity and accountability.

Zion HealthShare community members are expected to act with honor and integrity. Members should not falsify a medical need request, medical records, or use other deceptive practices. If a member abuses the trust of Zion HealthShare and its members, their membership may be revoked.

All Zion HealthShare members must attest to the following statements:

  • I believe that a community of ethical, health-conscious people can most effectively care for one another by directly sharing the costs associated with each other’s healthcare needs. I acknowledge that Zion HealthShare affiliates itself with, and considers itself accountable to, a higher power. I recognize that Zion HealthShare welcomes members of all faiths.
  • I understand that Zion HealthShare is a benevolent organization, not an insurance entity, and that Zion HealthShare cannot guarantee payment of medical expenses.
  • I have and will continue to practice good health measures and strive for a balanced lifestyle. I agree to abstain from the use of any illicit or illegal drugs and refrain from excessive alcohol consumption, acts which are harmful to the body. I understand that members who use tobacco will have an increased monthly contribution (per household) of $50.
  • I am obligated to care for my family. I believe that mental, physical, emotional, or other abuse of a family member, or any other person, is morally wrong. I am committed to treating my family and others with care and respect at all times.
  • I agree to submit to mediation followed by subsequent binding arbitration, if needed, for any instance of a dispute with Zion HealthShare or its affiliates.

MEMBERSHIP ELIGIBILITY

Membership eligibility in Zion HealthShare is primarily based upon two factors.

  1. Adherence to the Zion HealthShare’s Principles of Membership.
  2. Participation in the community by submitting monthly contributions.

After committing to these primary obligations, prospective members are eligible to enroll in the Zion HealthShare community. Membership may begin on a date elected by the prospective member or specified by Zion HealthShare. The prospective member’s monthly contribution must be received within 15 days of the agreed-upon start date. The first monthly contribution must be received before the membership is considered active.

Commitment

Members of Zion HealthShare commit to abide by a set of personal standards as outlined in the Zion HealthShare’s Principles of Membership. If a violation of the Principles of Membership is discovered through review of a member’s submitted medical records, all cost sharing for the medical need requests of that member will be put on hold. This hold will begin on the date in which the violation was discovered or recorded in the member’s medical records. A notification of the hold and an explanation of the discovery will be issued to the member.

The member will be granted 30 days to submit documentation supporting compliance with the Principles of Membership. If the submitted documentation does not satisfactorily demonstrate compliance with the Principles of Membership, the member will automatically be withdrawn from the sharing program and membership will be revoked. In the event that membership is revoked due to a violation of the Principles of Membership, Zion HealthShare will not return the offending member’s contributions received prior to the date of withdrawal.

Participation through Contributions

To participate in the member-to-member medical cost sharing community, members must submit the monthly contribution amount associated with their level of membership.

 

Members have multiple options for submitting their monthly contributions. Individual members can make contributions directly to Zion HealthShare. For members who enroll in Zion HealthShare through their workplace or a direct primary care practice (DPC), payments can be made through their employer or DPC practice.

 

All member contributions are voluntary, but the monthly contribution is required to be active and eligible for sharing. Monthly contributions must be received no later than 30 days after the billing date. If a monthly contribution is not received by the last day of the billing month, the membership will become inactive, and the member will be withdrawn from the medical cost sharing community.

 

Any member that has been withdrawn may reapply, provided they meet all enrollment and eligibility requirements. Once the member reapplies and membership is reinstated by Zion HealthShare, the member will become eligible to participate in cost sharing. All member medical need requests occurring after the membership is inactive and before reinstatement will be ineligible for cost sharing, and any medical conditions existing before the date of reinstatement will be considered pre-membership medical conditions.

Qualification

To be qualified for membership, an applicant must meet all criteria set forth in the membership guidelines and the membership enrollment form. If at any time it is discovered that a member did not submit a complete membership enrollment form,

the incomplete form could result in either a retroactive membership limitation or a retroactive denial of membership.

While member health status has no effect on eligibility for membership, there are limitations on medical cost sharing for some conditions that existed prior to a member’s effective date. Member need requests that do not qualify for medical cost sharing may still be met, whether in whole or in part, through the Additional Giving sharing program (see section titled Additional Giving).

Active Membership

To participate in medical cost sharing with the Zion HealthShare community, a membership must be active. Membership is considered active when the member has paid their monthly contributions on time and is in good standing with Zion HealthShare. For a medical need request to be shared, the membership must be active during the date(s) of service, when medical bills are received, and at the time the IUA is paid. If a membership deactivates before the determination of sharing is made, the bills will not be shared with the community. Any pre-membership medical condition limitations are applied based on the first date of active membership.

ENROLLMENT REQUIREMENTS

Zion HealthShare offers different enrollment types for individuals and families. Monthly contributions are based on the enrollment type, initial unshareable amount (IUA), and member age. This section outlines the different household memberships and who is eligible for enrollment therein.

Determination of Household Membership

There are four tiers of membership, and member contributions are calculated depending on the participating members of a household.

· Member Only: An individual member of Zion HealthShare

· Member & Spouse: Two married members or two members in a domestic partnership

· Member & Child(ren): A member and any eligible dependent children, without membership of a spouse

· Member & Family: A member, spouse, and any dependent children

Dependents

An unmarried dependent may participate under a combined membership with the head of household through the age of 25. Children born into a membership due to an eligible maternity need may participate under a combined membership. Under a combined membership, the head of household is responsible for ensuring that each individual participating under the combined membership complies with the Member Guidelines and the Zion HealthShare Principles of Membership.

Once a dependent reaches the age of 26 or marries, that dependent is no longer eligible to participate under the combined membership. A dependent who wishes to continue participating as a member with Zion HealthShare may complete an

enrollment form. Any medical need requests that occur between the time when a child leaves their parent’s membership and enrolls in their own are not shareable. If a dependent ages out of their Zion HealthShare membership but chooses to re-enroll at a later date, they will be subject to the limitations associated with pre-membership medical conditions.

Newborns

Newborns whose birth is part of a shareable maternity need must be enrolled by the parent within 30 days of birth. In the case of a change in household enrollment type, the monthly contribution amount will be adjusted automatically for the next billing cycle. If the parent does not enroll their newborn within 30 days, any conditions present at birth or that occur before the child’s enrollment date will be considered pre-membership medical conditions.

Newborns who are not born as part of a shareable maternity need must be enrolled manually in a Zion HealthShare membership. The newborn’s membership will begin on the date of enrollment but can be no sooner than seven days after delivery. Any genetic conditions or complications for newborns not born as part of a shareable maternity need are considered pre-membership medical conditions and subject to the same limitations as defined in the section “Pre-Membership Medical Conditions.”

Adoption

Zion HealthShare considers adopted children the same as biological children regarding membership. Any physical conditions of which the adoptive parents are aware prior to the legal adoption of the child are considered pre-membership medical conditions and are subject to the sharing limitations and phase-in period outlined in the Member Guidelines. Adopted children cannot be added to a Zion HealthShare membership prior to birth.

Grandchildren

A grandchild (or grandchildren) may be included as part of their grandparent’s membership if they meet the following criteria:

  1. The grandparent has legal custody of the grandchild.
  2. The grandchild lives with their grandparents at least nine months out of the year.
  3. There is no other agency, person, or group responsible for the grandchild’s medical needs.

 

Tobacco Users

Zion HealthShare households with one or more tobacco users are required to contribute a higher monthly contribution to maintain membership. The monthly tobacco surcharge is $50 per household.

A household member who has used any tobacco product one or more times a month within the past year is considered a tobacco user. Tobacco products include, but are not limited to, cigarettes, cigars, chewing tobacco, snuff, vape products, and pipe tobacco. Smoked cannabis products are considered tobacco for the purposes of the tobacco surcharge.

Determination of a “Medical Need”

This section explains how the shareable amount of a member’s medical expenses will be determined.

Medical need requests are submitted on a per member, per need basis. A medical need may be an injury or illness that results in medical expenses. These medical expenses may be incurred by receiving medically necessary treatment from licensed medical professionals and facilities, such as physicians, emergency rooms, and hospital facilities. Expenses related to the same medical condition, whether expenses for a single incident or separate incidents, will be shared as one medical need request.

When a member has a medical expense to be shared, the member must submit a medical need request. Once their medical need request is open, the member must submit original, itemized bills for the medical expense within six months of treatment. Bills submitted more than six months after the service date of treatment may be considered ineligible for sharing. There is no lifetime limit on the number of conditions or the total dollar amount that may be shared.

Medical Need Request Process

The process by which Zion HealthShare makes sharing decisions about healthcare expenses. To be shared with the community, expenses must be eligible according to the Member Guidelines.

Maximum Shareable Amount

There is no annual or lifetime maximum shareable amount for any member or membership household. Zion HealthShare has a systematic way to handle large medical need requests and has budgeted to account for them.

Insurance Companies

Insurance companies are primarily responsible for the payment of a member’s medical expenses. Members who are eligible for benefits through their insurance coverage must contact a Zion HealthShare member advisor before submitting their medical need request.

Failure to disclose insurance coverage may result in ineligibility for sharing. This includes primary insurance through a non-member spouse, family member, or employer. If you have primary insurance coverage, some expenses not covered by insurance may be shareable. Supplemental insurance policies are not considered relevant for this purpose.

Appeals

If a member believes that a limitation was incorrectly placed on member sharing, an appeal may be submitted. Members may submit an appeal and provide supporting medical evidence to have the membership limitation removed. All appeals are reviewed by a committee that includes at least one Zion HealthShare board member, as well as trained medical professionals.

Appeal requests must be submitted within 30 days of the need request determination and must be submitted by the member, not the member’s providers. Zion HealthShare can request additional information from providers.

To file an appeal, send the medical evidence, an explanation of why you feel that the limitation was placed unfairly, and any supporting documentation to needs@zionhealth.org.

The Initial Unshareable Amount

Initial Unshareable Amount (IUA)

 

The initial unshareable amount, or IUA, is the amount that a member will pay per medical need before the Zion HealthShare community shares in medical expenses. The IUA is also known as the member’s responsibility. Zion HealthShare has three primary levels of personal responsibility: $1,000, $2,500, and $5,000. The lower your personal responsibility (or IUA), the higher your monthly contribution will be.

After the IUA is met, additional qualifying medical expenses are shareable with the Zion HealthShare community. There is no annual or lifetime limit. You will not need to pay the IUA for a single medical need request again until you are symptom free for 12 months. Additionally, you will not be responsible for more than three IUAs in a rolling 12-month period.

Changing your IUA

Members may choose to change their IUA once per membership year. If an IUA is lowered, a 60-day waiting period will apply to all medical need requests other than those resulting from an accident.

Multiple Medical Need Requests in a 12-Month Period

Zion HealthShare provides a safeguard for households that experience more than three shareable needs in a 12-month period. After the member has paid three IUAs in that period, any additional shareable expenses of $500 or more will be shared with no IUA responsibility.

SUBMISSION OF MEDICAL NEED REQUESTS

Zion HealthShare strives to share in its members’ medical expenses in a timely, accurate manner. To do this, it is crucial for members to submit medical need requests correctly and include all required documentation.

Submitting a Medical Need Request

Medical need requests should be submitted through the Member Portal or Zion HealthShare website. Need requests should be submitted as soon as possible. Most nonemergency need requests, such as surgical procedures, should be submitted prior to the date of service. For any help with this process, members may contact Zion HealthShare directly during business hours.

• Phone 888-920-9466

• Email needs@zionhealth.org

Contact the Medical Advocacy team for early sharing requests. The Medical Advocacy Service is complimentary to all Zion HealthShare members. Our team of experts is here to help you find quality providers and facilities. We can even schedule appointments, help members obtain self-pay discounts, and pay ahead of time for eligible expenses.

Contact the Medical Advocacy team:

• Phone 888-399-0017

• Email advocacy@zionhealth.org

Required Documentation

When submitting a need request, members should submit any documentation received. Zion HealthShare may request other documents that may be required through the needs process. Document types can include receipts, proof of payment, bills, and statements.

 

Time Limit for Providing Documentation

Original, itemized bills should be submitted promptly to Zion HealthShare along with the medical need request form for Zion HealthShare to process your medical need request as soon as possible. In order to be shared, need requests must be submitted within six months of the date of service.

Meeting the IUA

Medical expenses are only shareable with Zion HealthShare after the member has met their IUA. Members should provide documentation to Zion HealthShare of all payments that may contribute toward the member’s IUA. The IUA must be paid within six months of the date of service or bills may become ineligible for sharing. Consideration will be given for situations where the cost of treatment has not exceeded the IUA after six months for a specific medical need request. Members must communicate with their Member Needs team representative about a timeline for IUA payment.

Paying at the Time of Service

Zion HealthShare is not insurance, so members should tell their provider they are a self-pay patient. This way, they can obtain self-pay discounts on services, which allows Zion HealthShare to keep membership contributions low. Members should obtain itemized bills and receipts to request payment or reimbursement from Zion HealthShare. In some cases, prepayment may be an option. Contact the Zion HealthShare Medical Advocacy team before receiving a medical service for prompt payment at the time of service.

Requesting Discounts

Sharing may take place prior to, at the time of, or after healthcare services are performed. For all purposes, members should present as self-pay patients and communicate costs and discounts as soon as possible to Zion HealthShare.

PRE-MEMBERSHIP MEDICAL CONDITIONS

To keep membership contributions low for all members, Zion HealthShare implements a waiting period for sharing of medical conditions that exist prior to enrollment in a Zion HealthShare membership. This section defines pre-membership medical conditions and outlines the sharing limitations.

Definition of Pre-Membership Medical Condition

A pre-membership medical condition is any illness or injury for which a person has

  • been examined,
  • been diagnosed,
  • taken medication,
  • had symptoms,
  • or received medical treatment

within 24 months prior to the effective date of membership. Medical need requests related to conditions that existed prior to membership are only shareable if the condition was regarded as cured and did not require treatment or present symptoms for 24 months prior to the effective date of membership.

Please Note: medical conditions that existed prior to membership may still qualify for sharing through the Additional Giving fund.

Pre-Membership Medical Condition Phase-In Period

Pre-membership medical conditions have a phase-in period wherein sharing is limited. Starting from the initial enrollment date, members have a one-year waiting period before pre-membership medical conditions are shareable. After the first year, pre-membership medical condition need requests are eligible for sharing. The shareable amount increases with each membership year.

Shareable amounts for pre-membership medical conditions:

  • Year One: $0 (waiting period)
  • Year Two: $25,000 maximum per need request
  • Year Three: $50,000 maximum per need request
  • Year Four: $125,000 maximum per need request

After year four of membership, expenses related to pre-membership medical conditions will remain shareable at a maximum of $125,000 in a 12-month period which resets each membership year.

Exceptions for High Blood Pressure, High Cholesterol, and Diabetes

High blood pressure, high cholesterol, and diabetes (types 1 and 2) will not be considered pre-membership medical conditions as long as the member has not been hospitalized for the condition in the 12 months prior to enrollment and is able to control it through medication or diet.

MEDICAL EXPENSES ELIGIBLE FOR SHARING

The following list reflects limitations on sharing for certain conditions or requirements for certain expenses to become eligible. All shareable expenses are subject to the member’s IUA.

Alcohol and Drug Abuse Treatment

Treatment for alcohol abuse, substance abuse, or chemical dependency is shareable up to $3,000 per member.

Alternative or Integrative Medical Practices

Alternative medical treatments may be shared with the Zion HealthShare community with prior written approval from Zion HealthShare. Alternative medical treatments without written approval may not be shareable. To be considered a viable alternative to a traditional treatment plan, these treatments must be considered safe and effective by Zion Health. A member is also required to demonstrate the proposed value of the alternative treatment.

What is needed for Zion HealthShare to consider an alternative medical need request?

  • Explanation of why the alternative medical treatment was selected
  • Doctor notes on current condition ( Zion HealthShare can help obtain doctor notes)
  • Estimated costs ( Zion HealthShare can help obtain the estimated costs, if appropriate)

Zion HealthShare considers alternative medical treatment plans on an individual basis and may put a cap on visits or shareable costs depending on the service. Once approved, sharing for the same medical need request may be limited if the member decides to return to traditional care methods.

Ambulance Transport

Medical transportation, including air and ground, is shareable as part of a medical need request when it is required in relation to a specific shareable illness or injury. Every effort should be made to be transported to the closest appropriate facility.

Arthritis Treatment

Degenerative and arthritic conditions are considered pre-membership medical conditions and may be shareable beginning in the second year of membership. Any treatment costs, including but not limited to joint injections, physical therapy, and chiropractic manipulations, are subject to the pre-membership medical condition phase-in period.

Audiological

Audiological treatment to correct hearing loss is shareable.

Automobile Accidents

Zion HealthShare will only consider bills for sharing after any relevant insurers have processed claims. This could include auto insurance after a car accident, a traditional health insurance policy, workers compensation, or liability insurance. Members should notify Zion HealthShare about any insurance policies they hold. Supplemental insurance policies are not considered relevant for this purpose.

Basal and Squamous Cell Cancer

Each individual location of a squamous cell or basal cell cancer requires a separate medical need request and separate IUA.

Breast Implant Removal

Breast implant removal is shareable only upon prior written approval from Zion HealthShare.

Cataract Surgery

Cataract surgery is treated as a pre-membership medical condition and subject to a one-year waiting period before it is shareable. Each eye requires a separate medical need request and is subject to an individual IUA.

Chiropractic Services

Services related to the treatment of a specific musculoskeletal injury or disease are shareable for up to 25 office visits per need request. All other chiropractic services will be treated as alternative medical practices and are subject to the limitations as outlined.

Congenital Conditions

Congenital conditions of children born outside a shareable maternity need request will be considered pre-membership medical conditions and therefore subject to the waiting period for cost sharing. See the Maternity Need Requests section for more information.

Cosmetic Surgery

Expenses related to cosmetic surgery are shareable only for disfiguration due to a shareable injury or illness.

Emergency Visits

Emergency room (ER) visits are generally shareable, whether or not they are in conjunction with an eligible medical need related to an illness, injury, or accident. The first ER visit for a medical condition is treated as a normal need request. Each additional visit related to the same condition requires the member to take on a personal responsibility of $500 in addition to the member’s IUA.

Members with nonemergency needs should seek out other treatment options such as doctor visits, telemedicine, urgent care clinics or other appropriate care.

Genetic Mutation

Medical need requests resulting from a genetic mutation that existed prior to membership are subject to the same limitations as other pre-membership medical conditions. If the member did not receive a diagnosis, require treatment, present symptoms, or take medication for the genetic mutation in the 24 months prior to membership, need requests related to the condition are considered for sharing without pre-membership medical condition limitations.

Genetic Testing

Genetic testing will only be considered for sharing if it is required for the personal treatment of a shareable condition, such as breast cancer.

Home Healthcare

Home healthcare expenses are shareable when related to an accident, illness, or injury and when the care has been prescribed by a licensed physician. Sharing of home healthcare expenses is limited to 30 days and $5,000.

Hospice Care

Hospice care is shareable for 90-day periods when ordered by, and under the care of, a licensed medical professional and upon physician approval or certification of terminal illness.

Hyperbaric Therapy

Inpatient or outpatient hyperbaric therapy may be shareable for the treatment of a specific illness or injury. Outpatient hyperbaric therapy is shareable for up to 35 therapy sessions.

Injections

Injections related to a shareable medical need request are shareable up to $5,000. Hormone therapy injections related to a shareable need request are shareable up to $3,000. Injections related to gender transitioning or sex reassignment therapy are not shareable.

International Medical Treatment

Medical expenses for emergency and acute care incurred outside the United States will be considered for sharing based on the Member Guidelines. Preventive or nonemergency services are not shareable without prior written approval from Zion HealthShare.

Joint Replacement Treatment

Beginning in the second year of membership, joint replacement treatment and surgery for degenerative arthritic conditions may be shareable. See “Arthritis Treatments” for more information.

Laboratory Tests and Checkups

Laboratory tests and checkups are considered part of a shareable need request when prescribed by a licensed medical provider.

Long-Term Care and Skilled Nursing

Long-term care and skilled nursing are shareable when prescribed by a licensed medical provider for recovery from a shareable injury or illness. Sharing for these services is limited to 90 days per medical need request.

Maternity

See the Maternity section of these guidelines for more details.

Contraception

Male and female contraceptive costs are not considered shareable. This includes but is not limited to IUDs, implantable contraceptive methods, and the “morning after” pill. Members can use Zion HealthShare’s discount program, RxShare, for prescribed oral contraceptive medications that are all available at a pharmacy. IUDs and other hormonal treatments for non-contraceptive purposes may be eligible for sharing.

Medical Equipment

Medical equipment, including durable medical equipment (DME), is shareable if it is prescribed by a licensed medical provider and if it is related to a shareable need request.

Medical Supplies

Medical supplies that directly aid in the treatment of, or recovery from, a shareable medical need request are generally shareable for up to 120 days from the treatment start date as prescribed by a licensed medical provider. Medical supply costs must be over $100 per item to be shared. Zion HealthShare will share the retail costs (or fair costs when applicable) and, thus, encourages members to use alternative vendors such as local pharmacies or medical supply stores.

Nutritionists

Expenses related to nutritionist services are not shareable unless prescribed by a licensed medical provider. Zion HealthShare must provide approval for nutritionist services prior to sharing.

Occupational Therapy

Occupational therapy is shareable for inpatient treatment and up to 35 outpatient sessions per medical need request, up to $7,500.

Organ Transplants

Organ transplants are shareable; however, they are subject to limitations for conditions existing prior to membership.

Pain Therapy

Pain therapy and treatment related to an eligible medical need may be shareable and subject to limitations described in our Member Guidelines for

  • injections
  • physical therapy
  • occupational therapy
  • chiropractic services
  • and therapeutic massage

Physical Therapy

Physical therapy is shareable for inpatient treatment and up to 35 outpatient sessions per medical need request, up to $7,500.

Prescriptions

Prescriptions for medications related to an eligible need request and billed by a provider are considered shareable.

Prescriptions filled at a pharmacy will be considered for sharing under the following conditions: 1) prior approval is given by Zion HealthShare, 2) the prescription is related to the treatment of a shareable medical need request, and 3) prescription costs exceed $500

monthly. Sharing for these prescriptions is limited to 12 months. Other prescription costs are generally not shareable. Members can receive prescription discounts through the Rx Share program. Many generic medications are available to members with Rx Share for $5 or $15 per month.

Speech Therapy

Speech therapy in relation to a shareable illness, injury, or accident is shareable for 35 outpatient visits per condition, up to $3,000. Speech therapy for conditions such as speech delays or learning impairments not caused by injury or accident is not shareable.

Sports

Medical expenses related to recreational sporting activities are generally shareable. Illness or injury resulting from practicing, or participating in, any semi-professional or professional competitive athletic contest for which the member receives any compensation is not shareable.

Suicide and Attempted Suicide

Zion HealthShare encourages members to take advantage of our LifeWorks program as a mental health resource. However, we understand that in the event of a dependent suicide, financial assistance can slightly ease the burden on our members. For this reason, Zion HealthShare will share in expenses related to the suicide or attempted suicide of an adolescent up to age 18. Up to $25,000 may be shared after one year of continuous membership.

Therapeutic Massage Therapy

Expenses related to therapeutic massage are shareable if the therapy is related to an eligible medical need request and prescribed by a licensed medical provider. Massage therapy is shareable for 25 sessions per need request, up to $3,000.

Tobacco Use over 50

Medical cost sharing for the medical need requests of tobacco users 50 years of age and older is limited to $50,000 for each of the following four disease categories:

• Stroke
• Cancer
• Heart conditions
• Chronic obstructive pulmonary disease (COPD)

Varicose Veins

Beginning in the second year of membership, evaluation and treatment for varicose veins may be shareable and is subject to the pre-membership medical condition phase-in period.

Weight Reduction

Beginning in the second year of membership, expenses related to weight reduction are shareable if prescribed by a licensed medical provider and approved by Zion HealthShare, up to $3,000 per medical need request.

MEDICAL EXPENSES INELIGIBLE FOR SHARING

The Zion HealthShare community chooses not to share in some medical expenses. Decisions for sharing eligibility are made to benefit the community as a whole, to keep monthly contributions low for our members, and to share in medical expenses based on our Principles of Membership. The following expenses are excluded from sharing with the Zion HealthShare community.

Abortion

Expenses for the abortion of a living, unborn baby are not shareable.

ADHD, ADHS, and SPD Treatment

Expenses for prescriptions related to ADHD, ADHS, and SPD are not shareable. Members can use Zion Health’s discount prescription program, Rx Share, for any prescribed medications that are available at a pharmacy.

Allergy Treatments

Allergy testing and medication is excluded from sharing. Members can take advantage of the Rx Share program to receive prescription discounts. Medical need requests that arise out of non-seasonal allergies, such as an emergency room visit for an allergic reaction, may be considered for sharing.

Dental

Tooth damage caused by an accident or injury may be considered for sharing. Other dental services, such as caps, crowns, root canals, fillings, wisdom tooth extraction, and cleanings are not shareable.

Diabetic Medication & Supplies

Any medical expenses related to supplies, testing, medication, or other implements used to treat insulin-dependent diabetes are not shareable.

Fertility

Expenses related to fertility evaluations and treatments are not shareable.

Genetic Screening

Genetic screenings are not eligible for sharing.

Hearing Aids

Expenses related to hearing aids are not shareable.

Injuries Obtained from Certain Acts

Injuries or illnesses resulting from participation in a riot, criminal act, euthanasia, assisted suicide, or other such acts are not shareable.

Injuries or illnesses resulting from being under the influence of alcohol or drugs while committing a criminal act, such as operating a motor vehicle while impaired, are not shareable.

Late Fees and Interest

Any late payment fees or interest charges that may accrue to medical bills before the member meets their IUA are the member’s responsibility—they are not shareable. Additionally, any late payment fees or interest charges caused by a member’s delay in providing necessary documentation to Zion Health are not shareable.

Medical Noncompliance

Failure or refusal to comply with a physician treatment plan or leaving a facility against medical advice (AMA) may result in ineligibility for sharing for the medical need request and any complications that arise.

Medically Stable Conditions

A shareable medical need may be considered medically stable when the treating provider determines that the condition is chronic and further treatment will not likely result in improvement. At this point, the need request is subject to review and may result in a determination of ineligibility for future sharing.

Mental Health

Expenses related to medications or other treatment for any mental health illness or condition are not shareable. Mental health conditions may include anxiety, depression, mental illnesses, and other psychological conditions. Through LifeWorks, Zion Health members may have access to mental health consultations. LifeWorks is available as an add-on to any membership. Members can use Zion Health’s discount prescription program, Rx Share, for any prescribed medications that are available at a pharmacy.

Sleep Apnea

Sleep apnea equipment and testing are not shareable with the Zion Health community.

Sterilization

Elective sterilization, such as tubal ligation and vasectomy, is not shareable.

Surrogacy

Expenses related to a surrogate pregnancy, whether or not the surrogate is a member, are not shareable.

Vision

Vision expenses related to hardware, such as glasses and contacts, are ineligible for sharing. Annual optometry wellness exam may be eligible for sharing as an annual provider visit depending on membership type.

Vitamins and Supplements

The cost of vitamins and supplements is not shareable.

PREVENTIVE SERVICES

Zion HealthShare shares preventive services in a limited capacity with the Direct Membership, or with the Preventive Sharing add-on for the Essential Membership. Preventive services are not subject to the IUA.

See the Preventive Medical Sharing Guide for more details.

Annual Provider Visit

Annual provider visits are shareable upon membership activation, and may be used for preventive visits, specialist visits, or other services as outlined in the Preventive Medical Sharing Guide. Zion HealthShare will share the member’s first qualifying submission; all other subsequent provider visits are the member’s responsibility until 12 months have passed since the qualifying visit.

Any additional services provided during the visit will be considered the member’s responsibility, including x-rays, labs, and other services. For these services, members may seek lower cost options through online or independent lab facilities by presenting as self-pay patients. Members should take advantage of the Medical Advocacy Service as a complimentary resource to help them locate low-cost facilities.

Colonoscopies

Colonoscopies are shareable after six months of continuous membership. Colonoscopies are shareable every 10 years starting at age 45.

A member’s first colonoscopy as a member of Zion HealthShare over age 45 is shareable. Future preventive colonoscopies may be shareable according to the guidelines in the Preventive Medical Sharing Guide.

Zion HealthShare colonoscopy sharing guidelines are based on recommendations from the US Preventive Services Task Force for colorectal cancer screening. Outside of these guidelines, colonoscopies are considered diagnostic and may be shareable as part of an eligible medical need request. Colonoscopies for high-risk members under 45 may be shareable with prior written approval from Zion HealthShare.

Mammograms

A yearly preventive mammogram is shareable beginning at age 40.

Zion HealthShare mammogram sharing guidelines are based on recommendations from the US Preventive Services Task Force. Additional mammograms are considered diagnostic and may be shareable as part of an eligible medical need request. Mammograms for high-risk members under 40 may be shareable with prior written approval from Zion HealthShare.

Zion HealthShare follows the guidelines of the American Cancer Society in determining high risk. Should you choose to have a mammogram before the age of 40, for us to consider those costs for sharing, we will require a referral from a licensed medical provider which must include a statement of your breast cancer risk. This statement may include risk factors such as: you have a BRCA1 or BRCA2 mutation; you are an untested family member of someone who has a BRCA1 or BRCA2 mutation; you have a history of chest radiation which occurred before age 30; that your lifetime breast cancer risk is 20% or greater based on your family history; you have a first degree relative with breast cancer; or that you have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes.

Youth Immunizations

Youth immunizations (up to 18 years old) are shareable after six months of continuous membership.

Well Child Checks

Well child visits and their associated immunizations are shareable. Following the Centers for Disease Control and Prevention guidelines, and recommendations from the American Academy of Pediatrics, Zion HealthShare will share in:

• up to six well child visits before the age of 12 months

• three between 12 months and 24 months

• two between 24 months and 36 months

Yearly visits after can be shared as the annual provider visit; sharing is limited to $250 for the office visit cost. Zion HealthShare limits payment toward vaccinations and administration fees, using the costs published on the CDC website as a guide. Immunizations must be given within 6 months of the age recommended by the CDC.

MATERNITY NEED REQUESTS

As a general rule, maternity needs are shareable and are treated like any other medical need request. View Zion HealthShare’s Maternity Guide to learn more.

View Zion HealthShare’s Maternity Guide to learn more.

General

As with any other medical need requests, expectant mothers pay a single IUA for all expenses related to their maternity need request. Shareable expenses may be related to miscarriage, prenatal care, postnatal care, and delivery. Please submit your maternity need request as soon as possible, but no later than 6 months from pregnancy confirmation so we can best assist you with your maternity need request.

Waiting Period

Pregnancy is considered to have existed prior to membership if conception occurs prior to or within the first 60 days of the membership.

Conception that occurs prior to membership or within the first 60 days of membership is not shareable. The conception date will be confirmed by medical records.

Newborns who are not born as part of a shareable maternity need must be enrolled manually in a Zion HealthShare membership. The newborn’s membership will begin on the date of enrollment but can be no sooner than seven days after delivery. Any complications that the newborn may have, or any medical conditions present at birth, will be considered pre-membership medical conditions. Such conditions are subject to the same waiting periods as other pre-membership medical conditions.

What is Shareable

PRENATAL

• Routine office visits

• Routine lab work

• Fetal non-stress test (after 36-weeks)

• Up to three standard ultrasounds (unless an unexpected complication requires additional scans)

• STD/STI screenings prescribed by a licensed practitioner as part of routine prenatal care

DELIVERY

• OB/GYN labor and delivery

• Cesarean

• Multiple births

• Hospital labor and delivery

• Hospital room and board

• Anesthesiologist

• Legally practicing midwives

• Home births

• Birthing centers

• Charges related to unexpected complications with mother

• One in-hospital pediatrician visit, including routine immunizations, routine lab work, and routine hearing tests (these are shareable when the baby is added to the membership within 30 days of delivery and when these services occur prior to discharge from hospital)

POSTNATAL

• Mother’s six-week postpartum checkup with pap test

• 2-week cesarean post-op appointment

What is Unshareable

PRENATAL

  • 3D & 4D ultrasounds
  • Most immunizations (such as flu shots)
  • Non-prescription supplements
  • Genetic testing, including but not limited to:o Amniocentesiso Inhibin A

    o Alpha-Fetoprotein Serum (AFP)

    o Any type of Nuchal Translucency (NT) ultrasounds

    o NIPT testing

    o Services by companies providing genetic testing

DELIVERY

  • Doula services
  • Birthing tubs (or other items
  • Placenta encapsulations
  • Circumcision
  • Diagnostic Hearing Screening (including Evoked auditory tests, BAEP, ABR, or BAER)

 

Other services may be ineligible as determined by Zion HealthShare. If you have questions about a specific service, please contact Zion HealthShare prior to receiving care.

POSTNATAL

• Breast pumps

• Lactation consultant

• Mother’s immunizations

• Postpartum counseling

• Additional postpartum services

If you have questions about a specific service, please contact Zion HealthShare prior to testing. All genetic testing will be the responsibility of the member.

Check-ups for the baby after delivery are not part of the maternity need request. They would be considered a separate need request and subject to Member Guidelines eligibility determination.

Complications related to the baby would be considered a separate need request and subject to eligibility determination based on the Member Guidelines.

IUA Payments

Like any other shareable medical expense, the IUA must be paid prior to any cost sharing. The IUA must be paid within six months of the first date of service, or the maternity need request may become ineligible for sharing. Consideration will be given for situations where the cost of treatment has not exceeded the IUA after six months. Please contact the Maternity Needs Department in this situation. Any late payment fees or interest charges incurred because of a late IUA payment are not shareable.

Zion HealthShare can take a one-time IUA payment over the phone, paid directly to us, to meet your IUA. Please speak with our Maternity Needs team to make an IUA payment over the phone. Members can also make payments directly to providers. Payments made directly to providers can count towards your IUA for shareable services. In the event of overpayment, IUA reimbursements can be given to the member. Zion HealthShare has two reimbursement periods: midway through the pregnancy and after delivery.

Home Births

Home births typically incur fewer expenses. If the costs are significantly lower for a home birth than for a hospital birth and the member is under the care of a licensed care provider, Zion HealthShare may partially waive the IUA for the maternity need request.

Separate Need Requests

Any additional need request of the baby after birth, whether the condition existed before or after birth (including congenital conditions), is separate from the mother’s maternity need request and will require a new medical need request submission and IUA for each baby. Expenses for any pregnancy or birth-related complications of the mother are considered for sharing as part of the maternity need request.

Premature Birth

The baby’s eligible need requests are considered shareable as part of an eligible maternity need, even if the baby is born prematurely. Any services not included in a standard maternity need would be considered a separate need for the baby and will require a new medical need request submission and new IUA for each baby.

In Vitro Fertilization (IVF)

Expenses related to fertility treatments are not shareable.

For pregnancies occurring by IVF or other “non-traditional” fertilization methods, Zion Health defines date of conception as the date the fertilized embryo is implanted in the uterus.

Miscarriage

Any expenses related to a miscarriage that is associated with an eligible maternity need are shareable if the costs exceed your IUA.

Expenses related to a miscarriage that is not associated with an eligible maternity need are shareable as a regular need request.

Gestational Diabetes

Gestational diabetes is considered a complication of pregnancy, and members who develop this condition are encouraged to follow the recommendations of their treating providers.

Gestational diabetes is not considered insulin dependent. Therefore, costs of medications prescribed to treat gestational diabetes, including insulin, can be shared according to our prescription sharing guidelines.

Members are encouraged to seek counsel from their OBGYN on dietary changes and exercise. Glucometers and test strips can be purchased at local pharmacies or online at reasonable costs. For these reasons, nutritionists, other therapists, and testing supplies are not shareable.

ADDITIONAL GIVING

Members are encouraged to contribute funds in addition to their standard monthly contributions. One hundred percent of Additional Giving contributions are placed in the Additional Giving fund, which is used solely to assist members who have a medical need request that would not normally qualify for sharing. Additional Giving funds are not subject to any administrative costs. Additional Giving is not mandatory, and members may contribute however much they feel is appropriate.

All members who fulfill their membership responsibilities and follow the Member Guidelines are eligible to apply for assistance through Additional Giving via an Additional Giving request. Members may apply when they have a need request that does not meet sharing eligibility guidelines.

Guidelines for Additional Giving

Medical need requests that do not meet the sharing guidelines may be eligible for an Additional Giving request for sharing from the Additional Giving fund.

• Members and other contributors may give additional funds to share within the community for a general or specific medical need request. Members are encouraged to share out of their surplus.

• Members looking to request sharing from the Additional Giving fund must still meet their IUA before the medical need request becomes eligible for sharing.

Members are encouraged to contribute funds in addition to their standard monthly contributions. One hundred percent of Additional Giving contributions are placed in the Additional Giving fund, which is used solely to assist members who have a medical need request that would not normally qualify for sharing. Additional Giving funds are not subject to any administrative costs. Additional Giving is not mandatory, and members may contribute however much they feel is appropriate.

All members who fulfill their membership responsibilities and follow the Member Guidelines are eligible to apply for assistance through Additional Giving via an Additional Giving request. Members may apply when they have a need request that does not meet sharing eligibility guidelines.

Guidelines for Additional Giving

Medical need requests that do not meet the sharing guidelines may be eligible for an Additional Giving request for sharing from the Additional Giving fund.

• Members and other contributors may give additional funds to share within the community for a general or specific medical need request. Members are encouraged to share out of their surplus.

• Members looking to request sharing from the Additional Giving fund must still meet their IUA before the medical need request becomes eligible for sharing.

• Members who apply for sharing from the Additional Giving fund may only have part of their costs shared.

End of Life Assistance

If a member, or a member’s dependent, dies after one year of uninterrupted membership,

financial assistance will be provided to the surviving family. The Zion HealthShare member

community will provide assistance upon receipt of a copy of the death certificate.

Financial assistance will be provided to the surviving family as follows:

• $10,000 upon the death of a primary member

• $10,000 upon the death of a dependent spouse

• $2,500 upon the death of a dependent child

THE MEDICAL ADVOCACY SERVICE

The Medical Advocacy Service is complementary to all Zion HealthShare members, and our team of experts is here to help you find quality providers and facilities. We can even help with scheduling appointments, locating the most affordable providers, and paying ahead of time for preventive services or other medical expenses that exceed the IUA.

Contact the Medical Advocacy team:

Phone 888-399-0017

Email advocacy@zionhealth.org 

MEMBER GUIDELINES DISCLAIMER

Zion HealthShare is not an insurance company. Neither this publication nor membership in Zion HealthShare are issued or offered by an insurance company. The purpose of these Member Guidelines is to help members understand and identify medical need requests that qualify for potential sharing and the process by which payments are made. The Member Guidelines are not for the purpose of describing to prospective members what amounts will be reimbursed by Zion HealthShare. While Zion HealthShare has shared all eligible expenses of its members to date, membership does not guarantee or promise that your eligible need requests will be shared. Rather, membership in the Zion HealthShare community merely guarantees the opportunity for members to care for one another in a time of need and present their medical need requests to other members as outlined in these Member Guidelines. The financial assistance members receive will come from other members’ monthly contributions and not from Zion HealthShare.

THIS PUBLICATION AND MEMBERSHIP IN ZION HEALTHSHARE SHOULD NEVER BE CONSIDERED A SUBSTITUTE FOR A HEALTH INSURANCE POLICY. IF THE MEMBERSHIP IS UNABLE TO SHARE IN ALL OR PART OF A MEMBERS ELIGIBLE MEDICAL NEEDS, EACH MEMBER WILL REMAIN SOLELY FINANCIALLY LIABLE FOR ANY AND ALL UNPAID MEDICAL NEEDS. THESE GUIDELINES DO NOT CREATE A LEGALLY ENFORCEABLE CONTRACT BETWEEN ZION HEALTHSHARE AND ANY OF ITS MEMBERS. NEITHER THESE GUIDELINES, NOR ANY OTHER ARRANGEMENT BETWEEN MEMBERS AND ZION HEALTHSHARE, CREATE ANY RIGHTS FOR ANY MEMBER AS A RECIPROCAL BENEFICIARY, A THIRD-PARTY BENEFICIARY, OR OTHERWISE. AN EXCEPTION TO A SPECIFIC PROVISION OF THESE GUIDELINES ONLY MODIFIES THAT PARTICULAR PROVISION AND DOES NOT SUPERSEDE OR VOID ANY OTHER PROVISIONS. THE DECISION BY ZION HEALTHSHARE TO REIMBURSE A MEMBER’S ELIGIBLE NEEDS DOES NOT AND SHALL NOT CONSTITUTE A WAIVER OF THIS PROVISION OR ESTABLISH BY ESTOPPEL OR ANY OTHER MEANS ANY OBLIGATION ON THE PART OF ZION HEALTHSHARE TO REIMBURSE A MEMBER’S ELIGIBLE NEEDS.

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Guideline Terms