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MEMBER

GUIDELINES

At Zion Health, we have re-imagined the HealthShare model to simplify the experience of 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 Health 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 Health was founded with the mission to re-imagine the medical cost sharing model to fit the needs of its members amid the rapidly changing environment of American healthcare.

OUR MISSION

Zion Health offers superior-quality service to its community. Our goal is to continually re-imagine the HealthShare experience as a member-focused community. Zion Health 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 Health must comply with the following requirements to maintain membership with Zion Health and remain eligible to participate in the medical cost sharing program. Adherence to the Zion Health Principles of Membership minimizes medical risks, encourages good health practices, and ensures member integrity and accountability.

All Zion Health 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 health care needs. I acknowledge that Zion Health affiliates itself with, and considers itself accountable to, a higher power. I recognize that Zion Health welcomes members of all faiths.
  • I understand that Zion Health is a benevolent organization, not an insurance entity, and that Zion Health cannot guarantee payment of medical expenses.
  • I agree 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 fifty dollars.
  • 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 commit 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 Health or its affiliates.

MEMBERSHIP ELIGIBILITY

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

  1. Adherence to the Zion Health’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 Health community. Membership may begin on a date elected by the prospective member or specified by Zion Health. 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 Health commit to abide by a set of personal standards as outlined in the Zion Health 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 needs 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 Health 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 Health. For members who enroll in Zion Health 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 Health, the member will become eligible to participate in cost sharing. All member needs occurring after the membership is inactivated and before reinstatement will be ineligible for cost sharing, and any medical conditions existing before the date of reinstatement will be considered pre-existing. Any member whose membership has been inactivated three times will not be eligible to reapply.

Qualification

To be qualified for membership, an applicant must meet all criteria set forth in the member 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 needs that do not qualify for medical cost sharing may still be met, whether in whole or in part, through the special needs sharing program associated with Additional Giving (see section titled Additional Giving).

ENROLLMENT REQUIREMENTS

Zion Health offers different enrollment types for individuals and families. Monthly contributions are based on the enrollment type, 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 Health
• 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 member guidelines and the Zion Health 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 Health may complete an enrollment form. Any medical needs 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 Health membership but chooses to re-enroll at a later date, they will be subject to the limitations associated with pre-existing 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-existing.

Newborns who are not born as part of a shareable maternity need must be enrolled manually in a Zion Health 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-existing and subject to the same limitations as defined in the section “Medical Conditions Existing Prior to Membership.”

Adoption

Zion Health regards 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-existing conditions and are subject to the sharing limitations and phase-in period outlined in the Member Guidelines.

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

Zion Health households with one or more tobacco users are required to contribute a higher Monthly Contribution amount to maintain Membership.  The tobacco surcharge for monthly membership is $50 per household.

Any tobacco product, including cigarettes, cigars, chewing tobacco, snuff, vape products, and pipe tobacco, used one or more times a month within the past 1 year is considered a tobacco user.

Smoked cannabis products are considered tobacco for purposes of the tobacco surcharge.

MEMBER RESPONSIBILITIES

All members of Zion Health share certain responsibilities to remain a part of the sharing program. Because the actions of one member can affect the entire community, each member will be held accountable for following these standards.

Member Contributions

Monthly membership contributions should be made in a timely manner. If contributions are not made within 30 days of the due date, the membership will be inactivated, and any needs will not be shareable. See “Participation through Contributions” for more information.

Proper Submission of Medical Needs to Zion Health

For Zion Health to share in a member’s medical expenses, the member is responsible for submitting a complete and correct need request within six months of the treatment date to Zion Health. This process is outlined in the section titled “Submission of Medical Needs.”

Trust & Accountability

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

HOW NEEDS ARE SHARED

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

Medical needs are submitted on a per member, per incident basis. Medical needs may be injuries or illnesses that result 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.

When a member has a medical expense to be shared, 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 will not be shareable. There is no lifetime limit on the number of conditions or the total dollar amount that may be shared.

Determination Of A “Need”

Expenses related to the same medical condition, whether expenses for a single incident or separate incidents, will be shared as one need. The related expenses will accumulate toward the total need amount.

Initial Unshareable Amount (IUA)

The initial unshareable amount, or IUA, is the amount that a member will pay before the Zion Health community shares in medical expenses. The IUA is also known as your personal responsibility. Zion Health 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.

All qualifying medical expenses submitted after the IUA is met are shareable with the Zion Health community at one hundred percent. There is no annual or lifetime limit. For each separate need, the Zion Health community will share medical costs after the IUA is met. You will not need to pay the IUA for a single need 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 needs other than those resulting from an accident.

Maximum Shareable Amount

There is no annual or lifetime maximum shareable amount for any member or membership household. Zion Health has a systematic way to handle large needs and has budgeted to address large needs.

Multiple Needs in a 12-Month Period

Member households that experience multiple needs will be responsible for up to three IUAs within a rolling 12-month period. After a member has paid three IUAs in a twelve-month period, any additional needs of $500 or more will be shared with the Zion Health community at one hundred percent.

Insurance Companies & Government Entities

Insurance companies and government entities are primarily responsible for the payment of a member’s medical expenses. Members who are eligible for benefits through either insurance or government assistance must contact a Zion Health member advisor before submitting their medical need.

Active Membership

To participate in medical cost sharing with the Zion Health 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 Health.

For a medical need 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-existing condition limitations are applied based on the first date of active membership.

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.

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 Health board member.

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.

MEDICAL CONDITIONS EXISTING PRIOR TO MEMBERSHIP

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

Definition: 24 Months Symptom and Treatment Free

Needs that arise from 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.

Any illness or injury for which a person has been examined, taken medication, had symptoms, or received medical treatment within 24 months prior to the effective date of membership is considered a pre-existing condition. For more information, please see the definition of pre-existing condition listed under “defined terms.”

Please note: needs that existed prior to membership may still qualify for sharing through the Additional Giving Fund.

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-existing conditions as long as the member has not been hospitalized for the condition in the past 12 months and is able to control it through medication and/or diet.

Exceptions for Other Medical Conditions

Zion Health recognizes that each member’s situation is different. Zion Health reserves the right to make exceptions for certain medical conditions on a case-by-case basis. Zion Health makes decisions in service to the community as a whole.

Pre-Existing Condition Phase-In Period

Pre-existing 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-existing conditions are shareable. After the first year, pre-existing needs are eligible for sharing on a limited basis, with the amount increasing each membership year. Members are never required to pay a second IUA for the same need, including pre-existing conditions.

Zion Health attempts to negotiate all medical bills received, and many membership types include the PHCS network for pre-negotiated medical expenses. Even if a pre-existing condition is not shareable, members may still receive discounts for their services through negotiation.

Shareable amount for pre-existing conditions:

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

After year four of membership, expenses related to pre-existing conditions will remain shareable at a maximum of $125,000 in a 12-month rolling period and resetting each membership year.

Members who enroll in the Zion Health Bridge Program through their employer are subject to the limitations in the program outline.

LIMITATIONS ON SHARING

Member needs not associated with a prior medical condition are generally shareable. The following list reflects limitations on sharing. All shareable expenses are subject to the member’s IUA.

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 Rx Share program to receive prescription discounts. Needs that arise out of non-seasonal allergies, such as an emergency room visit for an allergic reaction, are considered shareable.

Alternative Medical Practices

Alternative medical treatments may be shared with the Zion Health community with prior written approval from Zion Health. To be considered a viable alternative to a traditional treatment plan, these treatments must be considered safe and effective. A member is also required to demonstrate the proposed value of the alternative treatment.

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

• Explanation of why the alternative medical need was selected
• Explanation of why the alternative medical need should be shared
• Doctor notes on current condition (Zion Health can help obtain doctor notes)
• Estimated costs (Zion Health can help obtain the estimated costs, if appropriate)

Zion Health considers alternative medical treatment plans on an individual basis and may put a cap on visits or shareable costs depending on the service.

Alcohol and Drug Abuse Treatment

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

Ambulance Transports

Ambulance transports are shareable as part of a need when they are required in relation to a specific shareable illness or injury.

Audiological

Audiological needs to correct hearing loss are shareable. However, expenses related to hearing aids are not shareable.

Automobile Accidents

Needs arising from an automobile accident are only shareable when a third party or insurance entity is not liable. If the member’s medical need is being considered, or should be considered, by a third party or insurance entity, the need is not shareable until Zion Health receives documentation to reflect a lack of liability or partial payment.

Cataract Surgery

Cataract surgery is treated as a pre-existing condition and subject to the one-year waiting period before it is shareable. Each eye is considered a separate need and subject to an individual IUA.

Chiropractic

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

Chronic Pain Therapy

Services related to chronic pain therapy are treated as an alternative medical practice. They are shareable as part of a related eligible need, and members must get prior approval from Zion Health for the number and type of sessions. See the limitations on injections for more information.

Congenital Conditions

Congenital conditions of children born outside a shareable maternity need will be considered pre-existing and subject to the waiting period for cost sharing.

Cosmetic Surgery

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

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.

Emergency Visits

Emergency room visits are shareable for eligible medical needs related to an illness, injury, or accident. The first ER visit for a medical condition is treated as a normal need. 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. Seeking proper nonemergency care reduces emergency room visits and the financial strain on the entire community.

Fertility

Expenses related to fertility treatments are not shareable.

Genetic Mutation

Needs resulting from a genetic mutation that existed prior to membership are subject to the same limitations as other pre-existing 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, needs related to the condition are considered shareable without pre-existing 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. Genetic screenings are not eligible for sharing.

Home Healthcare

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

Hospice Care

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

Hospitalization

Hospitalization is shareable at a semi-private room rate. If a medical provider prescribes ICU or quarantine, those expenses are also shareable.

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 pain management for a shareable need are shareable up to $5,000. Hormone therapy injections related to a shareable need are shareable up to $3,000. Injections related to gender transitioning or sex reassignment therapy 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.

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 non-emergency services are not shareable without prior written approval from Zion Health.

Joint-Replacement Surgery

Joint replacement surgery for degenerative or arthritic conditions is treated as a pre-existing condition and is subject to the waiting and phase-in periods.

Laboratory Tests and Checkups

Laboratory tests and checkups are shareable as part of an eligible need and 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 an injury or illness. Sharing for these services is limited to 90 days per medical need.

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.

Medical Noncompliance

Failure or refusal to comply with a physician treatment plan and/or leaving a facility against medical advice (AMA) may result in ineligibility for sharing for the need and/or any complications that arise. The need will be subject to review and a determination made.

Medical Supplies

Medical supplies that directly aid in the treatment of, or recovery from, a shareable need 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 Health 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.

Medically Stable Conditions

A shareable 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 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 is not shareable. Mental health conditions may include anxiety, depression, mental illnesses, and other psychological conditions.

Through LifeWorks, some Zion Health members may have access to sharing of regular, preventive mental health consultations. LifeWorks is available as an add-on to any membership.

Naturopathic

Naturopathic care may be shareable pending written approval from Zion Health. Any expenses incurred prior to receiving written approval are not shareable.

Newborn Care

Routine care for a newborn without complications is included with an eligible maternity need.

NICU care and other complications are treated as a separate need of the baby. Expenses related to circumcision are excluded from sharing. Expenses related to infant immunizations are shareable with the Direct Membership or Connected add-on to the Essential Membership as outlined in the Preventive Medical Sharing Guide.

Nutritionists

Expenses related to nutritionist services are not shareable unless prescribed by a licensed medical provider. Zion Health 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 need, up to $7,500.

Organ Transplants

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

Physical Therapy

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

Prescriptions

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

Prescriptions filled at a pharmacy will be considered for sharing under the following conditions: prior approval is given by Zion Health, the prescription is related to the treatment of a shareable need, and prescription costs accumulate to $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.

Preventive Services

Preventive services are not subject to the IUA.

Zion Health shares preventive services in a limited capacity with the Direct Membership, or with the Connected add-on for the Essential Membership.

Annual office visits are shareable immediately upon membership activation, and may be used for preventive visits, specialist visits, or other services as outlined in the Preventive Medical Sharing Guide. Zion Health 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.

Colonoscopies, mammograms, and youth immunizations (up to 18 years old) are shareable after six months of continuous membership. Well child checks are shareable as outlined in the
Preventive Medical Sharing Guide.

See the Preventive Medical Sharing Guide for more details.

Sleep Apnea

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

Speech Therapy

Speech therapy in relation to an 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.

Sterilization

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

Suicide and Attempted Suicide

Zion Health 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 Health will share in expenses related to the suicide or attempted suicide of an adolescent up to age 18, up to $25,000 and after a one-year waiting period of continuous membership.

Surrogacy

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

Therapeutic Massage Therapy

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

Tobacco User Over 50

Medical cost sharing for the needs 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)

Vision

Zion Health may share in vision-related expenses that are deemed medical.

Weight Reduction

Expenses related to weight reduction are shareable if prescribed by a licensed medical provider and approved by Zion Health—up to $3,000 per need.

MATERNITY NEEDS

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

View Zion Health’s Maternity Guide to learn more.

General

As with any other medical need, expectant mothers pay a single IUA for all expenses related to their maternity need. Shareable expenses may be related to miscarriage, prenatal care, postnatal care, and delivery. STD screenings prescribed by a licensed practitioner as part of routine prenatal care are shareable as part of the maternity need. Maternity need requests must be submitted within 30 days from the date the member’s pregnancy is verified.

Separate Needs

Any need of the baby, whether occurring before or after birth, including congenital conditions, is separate from the mother’s maternity need. Expenses for any pregnancy or birth-related complications of the mother will be shared as part of the maternity need.

Early Sharing Request

A maternity care provider may reduce normal charges if a member prepays some or all of the bill. If this is the case, Zion Health will consider sharing the maternity need prior to delivery. To be considered for early sharing, the member must submit an estimate from the provider with the need request form.

IUA Payment

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 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 Maternity Needs in this situation. Any late payment fees or interest charges incurred because of a late IUA payment are not shareable.

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 Health may partially waive the IUA for the maternity need.

Pregnancy Prior to Membership

Conception that occurs prior to membership or within the first 60 days of membership is not shareable.

For any pregnancy that is not shared as an eligible maternity need with Zion Health, any newborn complications or medical conditions present at the time of birth are considered preexisting and are subject to the applicable waiting periods for sharing.

Waiting Period

Pregnancy is considered a pre-existing condition if conception occurs within the first 60 days of the membership. Zion Health requires notes from the first provider visit in order to verify the conception date.

Premature Birth

The baby’s needs are fully shareable, even if the baby is born prematurely. Any services not included in a standard maternity need would be considered a separate need of the baby.

ADDITIONAL GIVING

Members are encouraged to contribute funds in addition to their required 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 special need
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 membership guidelines
are eligible to apply for assistance through Additional Giving via an Additional Giving request.
Members may apply when they have a need that does not meet sharing eligibility guidelines.

Guidelines for Additional Giving:

  • Members and other contributors may give additional funds to share with the community for a general or specific need. Members are encouraged to share out of their surplus.
  • Members looking to request sharing from Additional Giving funds must still meet their IUA before the need becomes eligible for sharing.
  • Members who apply for sharing from the Additional Giving fund may only have part of their costs shared.

SUBMISSION OF MEDICAL NEEDS

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

Submitting a Need Request

Need requests should be submitted through the Member Portal or Zion Health website. Need requests should be submitted as soon as possible. Most non-emergency 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 Health directly during business hours.

Required Documentation

Need requests must contain all required documentation, including but not limited to the following:

  • Itemized bills
  • Proof of IUA
  • Medical records and other additional documents

 

Time Limit for Providing Documentation

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

Meeting the IUA

Needs are only shareable with Zion Health after the member has met their IUA. Members should provide documentation to Zion Health 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 need. Members must communicate with their Member Needs Team representative about a timeline for IUA payment.

Paying at the Time of Service

To make your experience as simple as possible, Zion Health can pay providers over the phone at the time of service for select preventive care as outlined in the Preventive Medical Sharing Guide.

Negotiating Medical Bills

Zion Health prefers to pay providers quickly and negotiate the best rates for healthcare services. This helps Zion Health keep rates low for members.

Members should inform Zion Health about any potential cash-pay discounts and consult with a member needs team associate prior to signing any payment arrangements. Zion Health is happy to participate in cost negotiations for its members.

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 Health 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

MEMBER GUIDELINES DISCLAIMER

Zion Health is not an insurance company. Neither this publication NOR membership in Zion Health are issued or offered by an insurance company. The purpose of these member guidelines is to help Members understand and identify medical needs 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 Health. While Zion Health has shared all Eligible Needs of its Members to date, membership does NOT guarantee or promise that your Eligible Needs will be shared. Rather, membership in the Zion Health community merely guarantees the opportunity for Members to care for one another in a time of need and present their medical needs to other Members as outlined in these member guidelines. The financial assistance Members receive will come from other members’ Monthly Contributions that are placed in a Benevolent Fund, and not from Zion Health.

THIS PUBLICATION AND MEMBERSHIP IN ZION HEALTH 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 HEALTH AND ANY OF ITS MEMBERS. NEITHER THESE GUIDELINES, NOR ANY OTHER ARRANGEMENT BETWEEN MEMBERS AND ZION HEALTH, 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 HEALTH 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 HEALTH TO REIMBURSE A MEMBER’S ELIGIBLE NEEDS.

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Guideline Terms