At Zion Health, we have reimagined 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.
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 reimagine the medical cost sharing model to fit the needs of its members amid the rapidly changing environment of American healthcare.
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.
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 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 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 in Zion Health is primarily based upon two factors.
- Adherence to the Zion Health’s Principles of Membership.
- 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.
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 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 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 medical need requests 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-membership medical conditions. Any member whose membership has been inactivated three times will not be eligible to reapply.
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).
Zion Health offers different enrollment types for individuals and families. Monthly contributions are based on the enrollment type, initial unshareable amount, 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
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 request 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 membership 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 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 Health membership but chooses to re-enroll at a later date, they will be subject to the limitations associated with pre-membership medical conditions.
Newborns whose birth is part of a shareable maternity need request 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 request 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 request are considered pre-membership medical conditions and subject to the same limitations as defined in the section “Pre-Membership Medical Conditions.”
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-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 Health membership prior to birth.
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.
Zion Health 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.
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.
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 medical need requests will not be shareable. See “Participation through Contributions” for more information.
Proper Submission of Medical Need Requests to Zion Health
For Zion Health to share in a member’s medical expenses, the member is responsible for submitting a complete and correct medical need request within six months of the treatment date to Zion Health. This process is outlined in the section titled “Submission of Medical Need Requests.”
Trust & Accountability
Zion Health community members are expected to act with honor and integrity. Members should not falsify medical need requests or medical records or use deceptive practices. If a member abuses the trust of Zion Health and its members, their membership may be revoked.
HOW MEDICAL NEED REQUESTS 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 “Medical Need Request”
Expenses related to the same medical condition, whether expenses for a single incident or separate incidents, will be shared as one medical need request.
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 the member’s 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.
After the IUA is met, all qualifying medical expenses are shareable with the Zion Health 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.
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 medical need requests and has budgeted to account for them.
Multiple Medical Need Requests in a 12-Month Period
If a member household experiences multiple needs within a rolling 12-month period, the member household will only be responsible for up to three IUAs within that period. After the member has paid three IUAs in a 12-month period, any additional shareable expenses of $500 or more will be shared with the Zion Health community with no IUA payment.
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 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, Zion Health will be the secondary payor, and some expenses not covered by insurance may be shareable.
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 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 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.
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.
Appeal requests must be submitted within 30 days of the need request determination and must be submitted by the member and not the member’s providers. Zion 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 firstname.lastname@example.org.
PRE-MEMBERSHIP MEDICAL CONDITIONS
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
Medical need requests 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
• taken medication,
• had symptoms,
• or received medical treatment
within 24 months prior to the effective date of membership is considered a pre-membership medical condition.
Please note medical conditions 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-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 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-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 on a limited basis, with the amount increasing each membership year. Members are never required to pay a second IUA for the same medical need, including pre-membership conditions.
Zion Health attempts to negotiate all medical bills received. Even if a pre-membership condition is not shareable, members may still receive discounts for their services through negotiation.
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 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.
MEDICAL EXPENSES ELIGIBLE FOR SHARING
Member need requests not associated with a pre-membership medical condition are generally shareable. 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.
Alternative Medical Practices
Alternative medical treatments may be shared with the Zion Health community with prior written approval from Zion Health. 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. 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 request?
- Explanation of why the alternative medical treatment was selected
- Explanation of why the alternative medical need request 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 are shareable as part of a medical need request when they are required in relation to a specific shareable illness or injury.
Degenerative and arthritic conditions are considered pre-membership 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 treatment to correct hearing loss is shareable.
Medical need requests arising from an automobile accident are only shareable when a third party or insurance entity is not liable. If the member’s medical need request is being considered, or should be considered, by a third party or insurance entity, the related expenses are not shareable until Zion Health receives documentation to reflect a lack of liability or partial payment.
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 removes are shareable only upon prior written approval from Zion Health.
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 subject to an individual IUA.
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.
Chronic Pain Therapy
Chronic pain treatments may be shared with the Zion Health community with prior written approval from Zion Health. These treatments must be considered safe and effective. The member is also required to demonstrate the proposed value of the treatment.
The following is needed for Zion Health to consider chronic pain therapy for cost sharing:
- Explanation from the member and provider of why the treatment was selected.
- Explanation from the member and provider of why the treatment costs should be shared.
- Doctor notes on current condition (Zion Health can help obtain doctor notes)
- Estimated costs (Zion Health can help obtain estimated costs if appropriate)
Zion Health considers chronic pain treatment plans on an individual basis and may put a cap on visits or shareable costs depending on the service.
Congenital conditions of children born outside a shareable maternity need request will be considered a pre-membership medical condition and will be subject to the waiting period for cost sharing.
Expenses related to cosmetic surgery are shareable only for disfiguration due to a shareable injury or illness.
Emergency room visits are generally shareable separately or in conjunction with an eligible medical need request 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. Seeking proper nonemergency care reduces emergency room visits and the financial strain on the entire community.
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 shareable without pre-membership condition limitations.
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 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 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 is shareable at a semi-private room rate. If a medical provider prescribes ICU or quarantine, those expenses are also shareable.
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 related to pain management for 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 non-emergency services are not shareable without prior written approval from Zion Health.
Beginning in the second year of membership, joint replacement treatment and/or surgery for degenerative arthritic conditions may be shareable. See “Arthritis Treatments” for more information.
Laboratory Tests and Checkups
Laboratory tests and checkups are shareable as part of an eligible medical 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.
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 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 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.
Naturopathic care may be shareable pending written approval from Zion Health. Any expenses incurred prior to receiving written approval are not shareable.
Routine care for a newborn without complications is included with an eligible maternity need request.
NICU care and other complications are treated as a separate need request 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.
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 is shareable for inpatient treatment and up to 35 outpatient sessions per medical need request, up to $7,500.
Organ transplants are shareable; however, they are subject to limitations for conditions existing prior to membership.
Physical therapy is shareable for inpatient treatment and up to 35 outpatient sessions per medical need request, up to $7,500.
Prescriptions for medications related to an eligible need request 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 medical need request, and 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 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.
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 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.
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:
• Heart conditions
• Chronic obstructive pulmonary disease (COPD)
Zion Health may share in vision-related expenses that are deemed medical.
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 Health, up to $3,000 per medical need request.
MEDICAL EXPENSES INELIGIBLE FOR SHARING
The Zion Health 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 Health community.
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 testing and medication is excluded from sharing. Members can take advantage of 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, are considered shareable.
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.
Expenses related to fertility evaluations and treatments are not shareable.
Genetic screenings are not eligible for sharing.
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.
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 medical need request and/or any complications that arise. The medical need request will be subject to review and a determination made.
Medically Stable Conditions
A shareable medical need request 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.
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 regular, preventive mental health consultations. LifeWorks is available as an add-on to any membership.
Sleep apnea equipment and testing is not shareable with the Zion Health community.
Elective sterilization, such as tubal ligation and vasectomy, is not shareable.
Expenses related to a surrogate pregnancy, whether or not the surrogate is a member, are not shareable.
Vitamins and Supplements
The cost of vitamins and supplements is not shareable.
Zion Health 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.
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 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.
Any additional services provided at the time of service will be considered the member’s responsibility, including x-rays, labs, and other services. For these services, members may seek lower cost options such as online or independent lab facilities by presenting as self-pay patients. Members should take advantage of the Medical Advocacy Service as a complementary resource to help them locate low-cost facilities.
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 Health over age 50 is shareable. Future preventive colonoscopies may be shareable according to the guidelines in the Preventive Medical Sharing Guide.
Zion Health 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 may be shareable with prior written approval from Zion Health.
A yearly preventive mammogram is shareable beginning at age 50.
Youth immunizations (up to 18 years old) are shareable after six months of continuous membership.
Immunizations must be administered within 6 months of the CDC recommended age to be considered shareable. For immunizations that do not qualify for sharing, we encourage you to contact your local health department as a low-cost option.
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 Health will share in up to six (6) well child visits before the age of 12 months, three (3) between 12 months and 24 months, and two (2) 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 Health 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 Health’s Maternity Guide to learn more.
View Zion Health’s Maternity Guide to learn more.
As with any other medical need request, expectant mothers pay a single IUA for all eligible maternity expenses. 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.
Separate Need Requests
Any additional medical expenses 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 will be shared as part of the maternity need request.
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 request prior to delivery. To be considered for early sharing, the member must submit an estimate from the provider with the maternity need request form.
Maternity Need Request Submission Deadline
Maternity need requests must be submitted no later than six months from the date the member’s pregnancy is verified at the initial provider visit.
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 Maternity Needs in this situation. Any late payment fees or interest charges incurred because of a late IUA payment are not shareable.
Zion Health can take a one-time IUA payment over the phone to be paid directly to us to meet your IUA. Please speak with our Maternity Needs team to make an IUA payments 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, reimbursements can be given to the member; however, there is a limit of 2 reimbursements per maternity need request.
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 request.
Patients experiencing gestational diabetes are encouraged to manage their gestational diabetes through diet, exercise, glucose monitoring, and oral medications if the glucose levels remain high despite changes in diet and exercise, reserving insulin for the more severely persistent glucose elevations.
Patients 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.
Gestational diabetes is not considered insulin-dependent; therefore, costs of medications, including insulin for the most severe cases, can be shared, according to our prescription sharing guidelines, when changes in diet and exercise and oral medications prove to be insufficient.
Pregnancy Prior to Membership
Conception that occurs prior to membership or within the first 60 days of membership is not shareable. Conception date will be confirmed by medical records and all members are subject to the Trust & Accountability clause in the Member Responsibility section of these guidelines.
For any pregnancy that is not shared as an eligible maternity need request with Zion Health, any newborn complications or medical conditions present at the time of birth are considered premembership medical conditions and are subject to the applicable waiting periods for sharing.
In Vitro Fertilization (IVF)
Expenses related to fertility evaluations and 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.
The baby’s needs are fully shareable, even if the baby is born prematurely. Any services not included in a standard maternity need request would be considered a separate medical need request for the baby and will require a new medical need request submission and IUA for each baby.
A miscarriage associated with a shareable maternity need request may be shareable if costs exceed your IUA.
A miscarriage not associated with a shareable maternity need request may be shareable as a medical need request.
Maternity Shareable Expenses
• Routine office visits
• Routine lab work
• Fetal non-stress test (after 36-weeks)
• Up to three standard ultrasounds. Additional ultrasound cost sharing will require Zion
Health review and approval, including those ordered for high-risk pregnancies.
• STD/STI screenings prescribed by a licensed practitioner as part of routine prenatal care
• OB/GYN labor and delivery
• Multiple births
• Hospital labor and delivery
• Hospital room and board
• 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 when the baby is added to the membership within 30 days of
delivery and when these services occur prior to discharge from hospital.
• Mother’s six-week postpartum checkup with pap test.
• 2-week cesarean post-op appointment
Maternity Unshareable Expenses
• 3D & 4D ultrasounds
• Most immunizations (such as flu shots)
• Non-prescription supplements
• Genetic testing, including but not limited to:
• Inhibin A
• Alpha-Fetoprotein Serum (AFP)
• Any type of Nuchal Translucency Ultrasounds
• “Third party” and genetic testing orderable online
• Doula services
• Birthing tubs (or other items related to midwife delivery)
• Placenta encapsulations
• Diagnostic Hearing Screening (including Evoked auditory tests, BAEP, ABR, or BAER)
• Complications related to the baby would be considered a separate need and subject to
member guideline eligibility determination.
• Breast pumps
• Lactation consultant
• Mother’s immunizations
• Postpartum counseling
• Additional postpartum services
• Check-ups for the baby after delivery may be shareable as part of a separate need request
and are subject to member guideline eligibility determination.
If you have questions about a specific service, please contact Zion Health prior to testing. Costs
of service that do not quality for sharing will be the member’s responsibility.
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:
Needs 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 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.
THE MEDICAL ADVOCACY SERVICE
The Medical Advocacy Service is complementary to all Zion Health members. our team of experts is here to help you find quality providers and facilities. We can even schedule appointments, negotiate costs beforehand, and pay ahead of time for preventive services or other medical expenses that exceed the IUA.
Contact the Medical Advocacy team
SUBMISSION OF MEDICAL NEED REQUESTS
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 Medical Need Request
Medical 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.
Medical need requests must contain all required documentation, including but not limited to the following:
- Itemized bills
- Proof of IUA payment
- Medical records and other additional documents
Time Limit for Providing Documentation
Original, itemized bills should be submitted promptly to Zion Health along with the medical need request form in order for Zion Health to process your medical need request 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
Medical expenses 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 medical need request. 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 self-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.