Member Guidelines History
June 1, 2023
October 1, 2022
Medical Advocacy
New section added about the Medical Advocacy Service.
Specific Sharing Qualifications – Section Name Change
“Specific Sharing Qualifications” renamed to “Medical Expenses Eligible for Sharing.”
Need – Term Change
All instances of the term “need” renamed to “medical need request” for clarity.
Medical Expenses Eligible for Sharing – Arthritis Treatments clause added
“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 condition phase-in period.”
Medical Expenses Eligible for Sharing – Basal and Squamous Cell Cancer clause added
“Each individual location of a squamous cell or basal cell cancer requires a separate need request and separate IUA.”
Medical Expenses Eligible for Sharing – Breast Implant Removal clause added
“Breast implant removals are shareable only upon prior written approval from Zion Health.”
Medical Expenses Eligible for Sharing – Chronic Pain Therapy clause clarified
“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 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.”
Medical Expenses Eligible for Sharing – Joint Replacement Treatment clause clarified
“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.”
Medical Expenses Eligible for Sharing – Weight Reduction clause added
“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 need.”
Maternity Need Requests – General Updates
Information from the Maternity Guide transferred to the Member Guidelines for clarity – including shareable and unshareable expenses.
Maternity Need Requests – Gestational Diabetes clause added
“Gestational diabetes is not considered insulin dependent. Therefore, costs of medications prescribed to treat gestational diabetes, including insulin, can be shared according to our prescription sharing guidelines.
Members are encouraged to seek counsel from their OBGYN on dietary changes and exercise. Glucometers and test strips can be purchased at local pharmacies or online at reasonable costs. For these reasons, nutritionists, other therapists, and testing supplies are not shareable.”
Maternity Need Requests – Maternity Need Request Submission Deadline clause added
“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.”
Preventive Services – Annual Provider Visit clause expanded
“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.”
Preventive Services – Colonoscopies clause clarified
“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 outlined in the Preventive Services section.
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 need.
Colonoscopies for high-risk members may be shareable with prior written approval from Zion Health.”
Preventive Services – Well Child Visits clause expanded
“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.”
Medical Expenses Ineligible for Sharing – Vitamins and Supplements clause added
“The cost of vitamins and supplements is not shareable.”
Medical Expenses Ineligible for Sharing – Injuries Obtained from Certain Acts clause expanded
“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.”
How Medical Need Requests Are Shared – Appeals clause clarified
“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.”
How Medical Need Requests Are Shared – Insurance Companies & Government Entities clause expanded
“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.”
Submission of Medical Need Requests – Negotiating Medical Bills
“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.”
*Other minor punctuation and grammatical changes were made for better readability.
Limitations on Sharing – Section Reorganized
Limitations on Sharing split into “Specific Sharing Qualifications” and “Medical Expenses Ineligible for Sharing”
Preventive Sharing – Section Reorganized
Preventive Sharing was made its own section for clarity, and some information from the Preventive Medical Sharing Guide was pulled into the Member Guidelines for ease of access.
Preventive Sharing – Youth Immunizations
“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.”
Pre-existing Conditions – Term change
Pre-existing conditions are now referred to exclusively as pre-membership medical conditions.
Enrollment Requirements – Determination of Household Membership
Domestic partnership added to Member & Spouse description.
Newborns – Automatic Enrollment Removed
“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.”
Limitations on Sharing – Chiropractic Care
120 day cap removed for sharing.
Limitations on Sharing – Congenital Conditions clause added
“Congenital conditions of children born outside a shareable maternity need will be considered pre-existing and subject to the waiting period for cost sharing.”
Limitations on Sharing – Dental clarification
“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.”
Limitations on Sharing – Diabetic Medication & Supplies clarification
“Any medical expenses related to supplies, testing, medication, or other implements used to treat insulin-dependent diabetes are not shareable.”
Limitations on Sharing – Genetic Testing clause added
“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.”
Limitations on Sharing – International Medical Treatment clause added
“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.”
Limitations on Sharing – Medical Noncompliance clause added
“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.”
Limitations on Sharing – Medically Stable Conditions clause added
“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.”
Limitations on Sharing – Sports wording clarified
“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.”
Maternity – Separate Needs clarification
“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.”
Maternity – IUA Payment clause added
“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.”
Maternity – Additional Clarifications
“Pregnancy” updated to “conception” for clarification.
First provider visit notes required with need submission.
Submission of Medical Needs – 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.”
Additional Giving
“Special Need Request” renamed to Additional Giving Request.
Pre-existing Conditions – Definition Change
“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.”
Preventive Sharing – Youth Immunizations Expanded
“Colonoscopies, mammograms, and youth immunizations (up to 18 years old) are shareable after six months of continuous membership.”
Preventive Sharing – Well-child Visits Added
“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.”
Newborns – Waiting Period Added
“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.”
Joint Replacement Surgery – New Clarification
“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.”
Additional Clarifications
Connected program changed to “Preventive Sharing.”
FAQ section updated and simplified.
Maternity – Updated to a single IUA
“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.”
Suicide and Attempted Suicide – New Clarification
“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.”
End of Life Assistance – Waiting Period Shortened
“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.”
Cataract Surgery – New Clarification
“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.”
Chronic Pain Therapy – New Clarification
“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.”
Preventive Services – Additional Clarifications
“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 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 16 years old) are shareable after six months of continuous membership.
See the Preventive Guide for more details.”
*Other minor punctuation and grammatical changes were made for better readability.
Prescriptions – Introducing Rx Share a new Generic medication prescription option.
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.
DISCOUNT PRESCRIPTIONS
Zion Health Rx program provides easy-to-use member-only discounts for generic, brand and specialty prescription(s).
Principles of Membership – Update
The following statement was added as part of principle one of the principles of membership.
“I also acknowledge that Zion Health has declared an affiliation with, and faith in, a higher power and welcomes members of ALL faiths.“
Physical Therapy & Occupational Therapy – Clarified inpatient maximum payout per need.
“Shareable for inpatient treatment and up to 35 outpatient sessions per need and up to $7,500.”
Speech Therapy – Clarified inpatient maximum payout per need.
“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.”
Therapeutic Massage Therapy – Clarified inpatient maximum payout per need.
“Shareable if prescribed by a licensed medical provider related to a shared need, up to 25 sessions and up to $3,000.”
Emergency Room – New Clarification
“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 Unsharable 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.”
Automobile Accident – Additional Clarification
“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.”
Home Births – New Potential IUA savings
“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 Unsharable Amount (IUA) for the child(ren) would still need to be met.”
Injections – New Clarification
“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 Unsharable Amount (IUA) for the child(ren) would still need to be met.”
Mental Health – Additional Options for Coverage
“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 that allows for regular preventive mental health consultations.”
Sleep Apnea – New Clarification
“Sleep apnea equipment and testing is not shared with the Zion Health community.”
Home Healthcare – New Clarification
“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.”
Medical Equipment – Additional Clarification
“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 – Additional Clarification
“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.”
Child Dependent Participation – Additional Clarification
“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.”
Dental – New Clarification
“Zion Health only shares in dental related expenses that are deemed medical.”
Vision – New Clarification
“Zion Health only shares in vision related expenses that are deemed medical.”
Appeal – Adding clarification on how to submit an appeal.
Added text:
“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 member@zionhealth.org.”
Participation – Updated requirement
Removed requirement to submit documentation each year but to simply agree to abide by the Principles of Membership.
Active Members – Clarify what needs are shared for active members
“For sharing with the community, the member must meet these requirements.
During time of Active Membership, the Initial Unsharable 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.”
Prescriptions – Clarified prescriptions that are shared
“Maintenance medications for conditions such as and not limited to blood pressure, cholesterol, thyroid, allergies, cannabis and diabetes are not sharable. Most medications can be purchased through discount prescription programs at a reasonable price and part of the Member responsibility.”
Allergy treatments – Added clarification on allergy needs
“Allergy testing, consultations and medication are excluded from sharing. Needs that arise out of non-seasonal allergies such as an ER visit from an extreme allergic reaction are considered shareable.”
Alternative Medical/Treatments – Clarified text
“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) “
Proper Submission of Medical Needs to Zion Health – Clarified timeline to submit medical needs and sharing in those needs
“Medical bills need to be submitted to Zion Health within six (6) months to be shared.”
Exceptions for pre-existing conditions
Removed – Exception for Hemorrhoids and Sleep Apnea
Added – Exception for diabetes (type 1 & 2)
Pre-existing condition phased in period – Clarify and added limitation on 4th year and beyond
“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’
Initial Unsharable Amount (IUA)
Added: a six (6) month lead period for medical bills to be considered part of the IUA