If you have heard of, or participated in, medical cost sharing communities, we invite you to take a closer look at Zion Health. We have reimagined the HealthShare concept to simplify the process, encourage healthy living, and make medical cost sharing more accessible. Our fresh approach is sure to captivate you!
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 health care costs in a simple yet practical way.
Members of HealthShare communities across the country share one another’s medical expenses in 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.
Membership eligibility in Zion Health is primary based upon two factors.
- Commitment to adhere to Zion Health’s Principles of Membership.
- Participation in the community by submitting monthly contributions.
To be considered for membership, prospective Members must enroll into the Zion Health community. Membership begins on a current or future date elected by the prospective member or on a date specified by Zion Health. The monthly contribution must be received within 15 days of a new Member’s effective date in order for the membership to become effective.
Members of Zion Health share a common commitment to abide by a set of personal standards outlined in its Principles of Membership. If at any time during participation in the membership, a violation of the Principles of Membership is discovered or revealed through the review of the Member’s submitted medical records, all needs of the Member in violation, submitted after the Date of Service in which the violation was discovered, will be put on hold. The Member will be issued an explanation of the violation and granted thirty (30) days to submit documentation supporting its compliance with the Principles of Membership, notwithstanding any contradicting information obtained by Zion Health before being withdrawn from the membership, rendering all needs ineligible. If the documentation and explanation submitted by such Member is not satisfactory to show compliance with the Principles of Membership, the Member will be automatically withdrawn from the sharing program and its membership will be revoked. In the event that a Member is withdrawn due to a violation of the Principles of Membership, Zion Health will not return Member contributions prior to the date of withdrawal, because contributions are submitted for Member to Member sharing.
To maintain an active membership with Zion Health, a Member must agree to abide by the Principals of Membership.
A Member must submit a Monthly Contribution associated with their membership level to Zion Health to be used for member-to-Member sharing. Monthly contributions are to be received each month and required to be received no later than thirty days of the billing date. If a Monthly Contribution is not received by the last day of a participating month, membership will become inactive. Any Member that has been withdrawn from the membership will be able to re-apply under the terms outlined to them in writing by Zion Health. Any Member who allows its membership to become inactive three consecutive times will not be able to re-apply for membership. Any Member’s needs occurring after they become inactive or before they re-apply for membership are ineligible for sharing.
Applicant(s) must meet all criteria set forth in a Membership Enrollment and the Membership Guidelines on the date of his/her application to be qualified for membership. If, at any time, it is discovered that a Member did not submit a complete membership, the incomplete membership could result in either a retroactive Membership Limitation or a retroactive denial of his/her membership.
While Member health status has no effect on eligibility for membership, there are limitations on the sharing of needs for some conditions that existed prior to a Member’s Effective Date. Needs that do not qualify for medical sharing may still be met in part or in whole through Special Needs Sharing Program.
A dependent may participate under a combined membership with the Head of Household through the age of 25. Once an unmarried child dependent turns 26, the child would need his or her own membership. A dependent who wishes to continue participating with Zion Health can by completing an enrollment. Children born into the membership, due to an eligible maternity need, can become a Member. Under a combined membership, the Head of Household is responsible to ensure that each individual participating under the combined membership meets and complies with the Principles of Membership and the Membership Guidelines.
Member contributions can be made directly with Zion Health, with a direct primary care practice or with a participating employer on a Member Contribution List. All Member contributions are voluntary, but the Monthly Contribution is required to be active and eligible for sharing.
An appeal can be submitted when a Member believes a limitation was incorrectly placed on Member sharing. Members may submit an appeal to have the Membership Limitation removed by providing medical evidence that they qualify for such removal.
To file an appeal send the medical evidence, explanation of why you feel that the limitation was placed unfairly and any other supporting documentation to email@example.com.
Members can choose from different levels of participation for Zion Health membership. Monthly share amounts are derived from household membership status and age.
Determination of Household Membership
Four tiers (Household Members):
Member & Spouse
Member & Child(ren)
Child Dependent Participation
Limited to children age 18 and younger, and unmarried children ages 19 through 25. Once an unmarried child dependent turns 26, the child would need his or her own membership.
When the dependent of a Member is married, he or she will not be a Member with Zion Health unless he or she re-enrolls in a Membership separate from the parents.
Married dependents and those over the age of 25 will no longer be considered part of their parents’ membership.
Any medical needs which occur from the time a child leaves his parents membership to the date he or she begins their own will not be shared.
Newborns whose addition to the household membership will increase the Monthly Contribution amount will be included within the household membership retroactive to the date of birth as long as the Member notifies Zion Health to add the child to the membership no later than 30 days after birth. Otherwise the effective membership date will be no earlier than the date of notification to Zion Health.
Adopted, unmarried children are considered members of the household the same as biological children. Any physical conditions of which the adopting parents are aware of for the adopted child prior to the legal adoption are considered pre-existing conditions and not shareable for the first year of membership as with any other member. Please see our section on pre-existing conditions to learn more about our phase-in period.
Grandchildren may be included as part of their grandparent’s membership if they meet all the following criteria.
1. They live with their grandparents at least 9 out of 12 months of each year;
2. The grandparents have legal custody of the grandchild; and
3. They have no other agency, person or group responsible for their medical needs.
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, 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.
Members should be aware of the responsibilities expected as part of the sharing program. Each Member’s actions can affect the whole community which is why it is very important to follow these standards.
Membership Shares or contributions should be made timely (within 30 days of due date).
Proper Submission Of Medical Needs To Zion Health
Submission of medical needs to Zion Health allows for timely and accurate sharing of a medical need. You can submit medical needs online, by phone or by your provider using your ID card. Providers can submit a “claim” form for your need electronically or by using our mailing address.
We like paying providers quickly and to negotiate the best rates for your healthcare services. This keeps providers happy and helps us keep rates low for our members. Keeping Zion Health in the loop with any potential “cash pay” discounts and consulting with us prior to signing payment arrangements can help us with the medical cost negotiations on your behalf.
Medical bills need to be submitted to Zion Health within six (6) months to be shared.
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 given, they will have their membership discontinued.
Zion Health practices good stewardship of the Benevolent Fund by adhering to these guidelines and limiting disbursements from the Benevolent Fund to the needs of those Members who comply with the Membership Requirements. Zion Health encourages Members to contribute as often and as much as possible in excess of their respective Monthly Contributions to enable Zion Health to assist those Members who have a Special Need. The receipt and administration of such additional contributions from the Members is part of the “Additional Giving Program”.
Additional attributes of the Additional Giving Sharing Program are set forth:
- Needs that do not meet the guidelines may be eligible for Additional Giving sharing requests. Members and other contributors may give additional funds for a general or specific need. Members looking to request sharing must meet a $500 threshold or above to be considered.
- Members who have needs during a given month may have only a part of the need shared. Members or other contributors can provide additional funds to share within the community. Members are encouraged to share out of their surplus.
- 100% of all contributions made to the Additional Giving program are shared for medical costs exclusively and not subject to administration costs.
NEEDS THAT MEMBERS SHARE
This section explains how the Shareable Amount of Member’s medical expenses will be determined. There is no Lifetime Limit on the number of conditions or the total dollar amount of different needs that may be shared. Original itemized bills for the medical expense Members want shared must be submitted within six months of treatment. Bills submitted more than six months after the service date of treatment will not ordinarily be shareable.
Medical needs are submitted on a per member, per incident basis. These are injuries and illnesses resulting in medical expenses incurred by receiving Medically Necessary treatment from Licensed Medical Professionals; including physicians, emergency rooms and hospital facilities.
Determination Of A “Need”
Expenses related to the same medical condition, including those for separate incidents, will be shared as one need and accumulate towards the total need amount. If at least 12 months pass without any symptoms, medication or other treatment for the original condition originally created the need, or related subsequent conditions recurs, it will be treated as a new need.
Initial Unshareable Amount (IUA)
Amount paid by the Member before the Zion Health community shares in Medical Expenses. This amount 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 the Initial Unshareable Amount, the higher the monthly sharing contributions.
All qualified medical expenses submitted within six (6) months of service and after the IUA is met, are shareable with the Zion Health community at 100% and without an annual or lifetime limit. For each medical need, the community shares in medical expenses after the initial unshareable amount (IUA) is met. This amount paid by the member does not need to be paid again until you are symptom free for 12 months. In this way we are sharing in the larger medical expenses that our members have as a community.
Maximum Shareable Amount
There is no lifetime maximum amount eligible for sharing for any Member or household. Zion Health has a systematic way to handle large needs and has budgeted to address large needs as they come in on a monthly basis.
Multiple Needs Within A 12-Month Period
Member households that experience multiple needs within a 12-month rolling membership year are asked to pay up to three Initial Unshareable Amount per year. Additional needs that meet a $500 threshold would be considered fully shareable with the Zion Health community.
Insurance Entities And/Or Government Programs
Insurance and/or government entities are always considered primary payer for any Members medical expenses. Members who are eligible for benefits through either insurance arrangements or government programs are required to contact Zion Health’s Member advisor before submitting their medical need to work through the claim or needs processing.
Members need to be active for sharing with the community. Active Members have paid membership contributions on time and in good standing with the Zion Health community.
For sharing with the community, the member must meet these requirements.
- During time of Active Membership the Initial Unshareable Amount (IUA) need to be paid.
- Date of service for medical expenses need to be during Active Membership.
- Medical bills must be received during time of Active Membership.
- Any limitations (IE: Pre-Existing Conditions) apply based on the Date of Service of any medical expenses as an Active Member.
Time Limit For Sharing Documentation
Receiving the bills and needs request promptly will help Zion Health to provide the speedy processing of your need. When there is a number of bills related together in one need, it is helpful for these bills to be submitted at one time if obtained within a 30-day period.
Original and itemized bills should be submitted to Zion Health with a need handling form as soon as possible. Bills and needs requests should be submitted within six (6) months from the Date of Service to be shared.
Late Fees and/or Interest
Any late payment fees and/or interest charges that accrue with medical bills prior to the IUA not being met, will not be sharable with the Zion Health community and will be the members responsibility. Additionally, late payment fees assessed and/or interest charges that are caused by the member’s delay in providing bills or information needed to process are also not shared with the Zion Health community.
MEDICAL CONDITIONS EXISTING PRIOR TO MEMBERSHIP
Medical expenses for any service or treatment provided during membership which meets these guidelines are shareable while being a Member in good standing except as explained below.
Conditions cured and 24-month symptom and treatment free
Needs that come from conditions that existed prior to membership are only shareable if the condition was fully cured and did not require treatment or present symptoms for 24 months prior to membership effective date.
Any illness or accident for which a person has been diagnosed, received medical treatment, been examined, taken medication for, or had symptoms of within 24 months prior to membership effective date are not shareable. For more information see pre-existing conditions definition.
Please note: Needs that existed prior to membership may still qualify for sharing using the Additional Giving Fund.
Exclusion of Diabetic Medication & Supplies
Medication and supplies (testing, etc) to treat insulin dependent diabetes are not shareable.
Exceptions for High Blood Pressure, High Cholesterol & Diabetes
High blood pressure, high cholesterol and diabetes (type 1&2) will not be considered a pre-existing condition as long as they have not been hospitalized for the condition in the past 12 months and able to control through medication or diet.
Exceptions for certain other medical conditions
Zion Health recognizes that every situation is different. Zion Health reserves the right to make exceptions for certain medical conditions on a case by case basis provided it serves to benefit the membership as a whole.
Pre-existing condition phased in period
Pre-existing conditions have a waiting or phase in period. Zion Health attempts to negotiate all medical bills received and many membership types include the PHCS network for pre-negotiated medical expenses.
- 1st Year of Membership – Waiting period of all pre-existing conditions
- 2nd Year of Membership – Up to $25,000 of sharing for pre-existing conditions
- 3rd Year of Membership – Up to $50,000 of sharing for pre-existing conditions
- 4th Year of Membership and Beyond – Up to $125,000 of sharing for pre-existing conditions per year
LIMITATIONS ON SHARING
Member needs that result from expenses not associated with a prior medical condition are generally shareable. The following chart reflects limitations of the plan. All shareable conditions are subject to the Member Initial Unshareable Amount.
Needs resulting in expenses for abortion of a living unborn baby will not be shared.
ADHD, ADHS and SPD Treatment
No sharing of prescriptions related to ADHD, ADHS and SPD. Members can utilize Zion Health’s discount prescription program for any prescribed medications available at the pharmacy.
Allergy testing and medication is excluded from sharing. Needs that arise out of non-seasonal allergies are considered shareable.
Alternative Medical Needs/Practices
Alternative medical treatments can be shared with the Zion Health community. These alternatives generally should be considered safe and effective while being an alternative to a traditional treatment plan. Needs may be considered shareable pending prior written approval by Zion Health. Member is required to demonstrate the proposed value of the alternative treatment.
What is needed to consider an Alternative Medical Need?
- Doctor notes on current condition (we can help to obtain the doctors notes)
- Explanation of why the alternative medical need was selected
- Explanation of why the alternative medical need should be shared
- Estimated costs (we can help to obtain the estimated costs if appropriate)
Alcohol or drug abuse treatment
Treatment for alcohol, substance abuse or chemical dependency is shareable up to the $3,000 Maximum Shareable Amount per Member.
Shareable as part of a need whenever medically needed or due to severity, proximity and circumstances associated with a specific illness or injury.
Shareable to correct hearing loss but not for hearing aids.
Only shareable when other third party and/or insurance entity is not liable. If the member’s medical need is being considered or should be considered by a third party and/or insurance entity, Zion Health will not share until documentation is received to reflect the lack of liability or partial payment.
Services related to treatment of a specific musculoskeletal injury or disease are shareable for up to 25 Office Visits and includes related items for treatment for up to 120 days. All other chiropractic services will be treated as “Alternative Medical Practices”.
Shareable only for disfiguration due to shareable injury or illness.
Zion Health only shares in Dental related expenses that are deemed medical.
Shareable for eligible medical needs from an illness, injury or accident. Each additional visit to the emergency room after the first visit for a single medical need requires the member to pay an additional $500 of personal responsibility. This amount is added to the members Initial Unshareable Amount (IUA). Members with non-emergency needs should seek out other treatment options such as telemedicine, doctor visits, urgent care clinics or other appropriate care.
Home Healthcare expenses are sharable when related to an accident or injury and prescribed by a licensed physician. Sharing is limited to 30 days and $5,000.
Shareable for 90-day periods with physician approval or certification of terminal illness.
Shareable at semi-private room rate or if a licensed medical provider prescribes ICU or quarantine.
Shareable for treatment of specific illness or injury. Outpatient included with up to 35 as a maximum number of therapy sessions.
Injections related to pain management for a sharable need is sharable up to $5,000. Hormone therapy injections related to a sharable need are shareable up to $3,000. Gender changing related injections are not shared.
Injuries obtain from certain acts
Injuries or illnesses caused by a result of participating in a riot, criminal act, assisted suicide or euthanasia will not be shareable.
Laboratory Tests and Checkups
Shareable only when prescribed by a licensed medical provider due to symptoms of a condition not in existence prior to membership.
Long-term Care and Skilled Nursing
Shareable as a result of recovering from an injury or illness as prescribed by a licensed medical provider. Sharing limited to 90 days per medical need.
Medical equipment including durable medical equipment (DME) can be shared if prescribed by a licensed medical provider and part of a need and approved by Zion Health.
Medical supplies directly aid in the treatment or recovery of a sharable medical need and generally shareable within 120 days of the treatment start date as prescribed by a licensed medical provider. Supplies costs need to be over $100 to be shared. Zion Health will share in the retail or fair costs when applicable and encourage members to utilize alternative vendors such as local pharmacy or medical supply stores.
Medications and other care is not shareable for the treatment of any mental health related illnesses. Mental health also includes anxiety, depression, mental illnesses, and psychology related conditions. Zion Health provides a mental health membership add-on (available 1/1/2021 – more information to come soon!) that allows for regular preventive mental health consultations by phone.
Shareable pending written approval from Zion Health.
Circumcisions are excluded from sharing
No immunizations unless you have the Direct Membership or Connected DPC. These memberships include the following immunizations:
Diphtheria, Tetanus, Pertussis (Whooping Cough), Haemophilus influenza type b, Hepatitis A, Hepatitis B, Human Papillomavirus (HPV), Inactivated Poliovirus, Influenza (flu shot), Measles, Meningococcal, Pneumococcal, Rotavirus, Varicella (Chickenpox).
Generally, not shareable unless prescribed by a licensed medical provider. Approval needs to be provided prior to sharing.
Shareable for inpatient treatment and up to 35 outpatient sessions per need, up to $7,500.
Shareable subject to limitations for conditions prior to membership.
Sleep apnea equipment and testing is not shared with the Zion Health community.
Shareable for inpatient treatment and up to 35 outpatient sessions per need, up to $7,500.
RELATING TO NEEDS
Prescriptions for medication(s) that are billed by a provider and are related to a qualified Need are also considered sharable. With Zion Health’s approval, large prescription costs associated with a Need that are filled at the pharmacy can be shared.
Rx SHARE (available starting 10/1/2020)
Generic medications are sharable with Zion Health’s Rx Share program. Brand and specialty drugs are also available at a discount. This prescription sharing program is included with the Zion Health Direct Membership or as an add-on to our other membership types.
Zion Health Rx program provides easy-to-use member-only discounts for generic, brand and specialty prescription(s).
Zion Direct Membership – Preventive doctor visits are shared right away. Colonoscopies, mammograms and youth (ages 0-16) immunizations are shared after one year of continuous membership. Preventive services are provided in-network only through PHCS or when authorized from Zion Health. Preventive services are not subject to the initial unshareable amount (IUA).
Connected Health – Preventive doctor visits colonoscopies, mammograms and youth (ages 0-16) immunizations are shareable right away. Preventive services are provided in-network only through PHCS or when authorized from Zion Health. Preventive services are not subject to the initial unshareable amount (IUA).
DPC Membership – Preventive services are not included in the regular DPC Membership. See Connected Health add-on to include these services.
Worksite Membership – Preventive services are not included in regular Worksite Membership. See Connected Health add-on to include these services.
Shareable in relation to an illness, injury or accident. Up to 35 outpatient visits per condition and up to $3,000. Sharing for Speech Therapy is excluded for speech delays or learning impairments not caused injury or accident.
Zion Health shares in sporting activities.
Injuries or illnesses resulting from participation in Modern Professional Boxing is not shareable.
Injuries or illnesses resulting from recreational karate, jiu jitsu, taekwondo or other combat sports are okay to share when not paid to win or compete.
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.
Therapeutic Massage Therapy
Shareable if prescribed by a licensed medical provider related to a shared need, up to 25 sessions and up to $3,000.
Tobacco User Over 50
Medical needs for tobacco users age 50 and older are limited to $50,000 for each of the following four disease categories: Cancer, Heart conditions, COPD and Stroke.
Zion Health only shares in vision related expenses that are deemed medical.
Shareable only if prescribed by a licensed medical provider and approved by Zion Health. $3,000 Maximum Shareable Amount per Member.
As a general rule, maternity needs are treated like any other medical expenses and are shareable. These expenses include prenatal care, delivery, postnatal care and miscarriage.
View Zion Health’s Maternity Guide to learn more.
Maternity needs are treated like any other medical expenses and are shareable. These expenses include prenatal care, delivery, postnatal care and miscarriage.
Bills for all pregnancy and birth related complications of the mother will be shared as part of the maternity need. Two initial unshareable amounts (IUA’s) are applied to a single maternity need.
Any pre-birth or post birth need of the child will be considered a separate need from the mother’s maternity care.
Early Sharing Request
If a maternity care provider will reduce the normal charges if a Member prepays some or all the bill, Zion Health will consider sharing the maternity need prior to the birth. The Member must request an estimate and submit it with the need request.
Home births have less expenses typically. Zion Health may waive one Initial Unshareable Amount (IUA) for the mother if the costs are lower than what otherwise would be paid by the sharing community and approved by Zion Health. The Initial Unshareable Amount (IUA) for the child(ren) would still need to be met.
Pregnancy Prior to Membership
Pregnancies prior to membership, or within the waiting period, are not considered shareable. A newborn child of a pregnancy that was conceived prior to membership will be added as a dependent seven days after their birth.
Pregnancies are considered pre-existing if the pregnancy start date is within the first 60 days of the membership effective date.
The baby’s needs are fully shareable for the baby born prematurely.
END OF LIFE ASSISTANCE
For a Member, and/or his or her dependents, who die(s) after two years of uninterrupted Membership as a Sharing Member, financial assistance to the surviving family will be provided by the Members according to the following schedule, upon receipt of a copy of death certificate, and as listed on the Member enrollment.
SUBMISSION OF MEDICAL NEEDS
Eligible medical expenses will be shared for all household members who meet all qualifications. Member should carefully follow instructions for submitting their needs requests.
- Qualification based upon lifestyle choices & medical history.
- Member has a need.
- Member contacts Zion Health.
- Needs Request Completed & Submitted to Zion Health (within 6 months)
- Zion Health Reviews Medical Needs
- Zion Health Advocates Need, Including Negotiation of Need Amount
- Zion Health Funds Qualified Need
- Need Completed
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 membership guidelines is to help Members understand and identify medical needs that qualify for potential reimbursement and the process by which reimbursements are made. The membership 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 membership 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.