Member Guidelines

Zion HealthShare offers superior quality service to our community. Our goal is to change the healthcare industry by connecting like-minded individuals to an innovative and affordable medical cost sharing community. We are a community that employees are proud to be a part of, medical professionals prefer for their patients, and members love and recommend to their family and friends.

Principles of Membership

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

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 If a member abuses the trust of our community, their membership may be revoked or withdrawn.

All Zion HealthShare members must attest to the following statements:

Principles of Membership

1. I believe that a community of ethical, health-conscious people can most effectively care for one another by directly sharing the costs associated with each other’s healthcare needs. I acknowledge that Zion HealthShare affiliates itself with, and considers itself accountable to, a higher power. I recognize that Zion HealthShare welcomes members of all faiths.

2. I understand that Zion HealthShare is a benevolent organization, not an insurance entity, and that Zion HealthShare cannot guarantee payment of medical expenses.

3. I will practice good health measures and strive for a balanced lifestyle. I agree to abstain from the use of any illicit or illegal drugs and refrain from excessive alcohol consumption, acts which are harmful to the body. I understand that members who use tobacco will have an increased monthly contribution (per household) of $50.

4. I am obligated to care for my family. I believe that mental, physical, emotional, or other abuse of a family member, or any other person, is morally wrong. I am committed to always treating my family and others with care and respect.

5. I agree to submit to mediation followed by subsequent binding arbitration, if needed, for any instance of a dispute with Zion HealthShare or its affiliates.

Membership Eligibility

Membership eligibility is primarily based on:
1. Adherence to the Zion HealthShare Principles of Membership.
2. Participation in the community by submitting monthly contributions.
3. Reside in the United States or Puerto Rico.

After committing to these primary eligibility requirements, prospective members are eligible to join the Zion HealthShare community. Membership may begin on a date selected by the prospective member or specified by Zion HealthShare, known as the membership start date. The prospective member’s monthly contribution must be received within 15 days of the agreed-upon membership start date. Once the first monthly contribution has been received membership is considered active.

Commitment

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

Members will have 30 days to submit documentation supporting compliance with the Principles of Membership. If submitted documentation does not satisfactorily demonstrate compliance, membership may be revoked. If membership is revoked due to a violation of the Principles of Membership, Zion HealthShare will not return the offending member’s contributions received prior to the date of revocation.

Participation Through Contributions

Members submit monthly contributions (based on their membership IUA option) to participate in the medical cost sharing community. Direct members can make their contributions directly with Zion HealthShare. Essential members can make monthly contributions through their employer or DPC practice.

Participation in the medical cost sharing community is voluntary, but monthly contributions are required for active membership and sharing eligibility. Monthly contributions must be received no later than 30 days after the contribution 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.

Withdrawn members may reapply if they meet all eligibility requirements. Once the member reapplies and membership is reinstated by Zion HealthShare, the member will become eligible to participate in our medical cost sharing community. All sharing requests submitted after the membership is inactive and before reinstatement will be ineligible for member-to-member sharing, and any medical conditions existing before the member is reinstated will be considered pre-membership medical conditions.

Qualifications

Applicants must meet all criteria in the Member Guidelines, Principles of Membership, and membership application form to qualify for membership. If, at any time, it is discovered that a member did not submit a complete membership sign-up form, membership may be retroactively withdrawn or revoked.

While member health status has no effect on eligibility for membership, there are sharing limits for some pre-membership medical conditions. Sharing requests that are not eligible for sharing may still be shareable through the Additional Giving fund.

See the Additional Giving section for details.

Active Membership

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

Residency Statement

Zion HealthShare members must reside within, and be a resident of, the United States or Puerto Rico to participate in and contribute to medical cost sharing. Members who choose to move outside of the United States or Puerto Rico must notify Zion HealthShare in writing within 15 days of moving, and the membership will be withdrawn.

Membership Requirements

Zion HealthShare offers different membership options for individuals and families. Monthly contributions are based on the membership type (Direct or Essential), age group, and initial unshareable amount (IUA).

Determination of Household Membership

There are four membership tiers, differentiated by the number of members taking part in the household membership.
·       Member Only: An individual member
·       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 or domestic partner
·       Member & Family: A member, spouse or domestic partner, and any dependent children

Dependents

An unmarried dependent under 26 years of age, and any child born into a membership in connection with an eligible maternity sharing request, may participate under a household membership with the Primary Member. The Primary Member is responsible for ensuring that each individual participating under the household membership complies with the Member Guidelines and our Principles of Membership.

When a dependent turns 26 or marries, that dependent can no longer participate under the household membership. A dependent who wishes to continue as a member with us may complete an application form. Any sharing requests that occur between the time when a dependent leaves a guardian’s membership and begins their own are not shareable.
Dependents who age out of a membership but later choose to re-join will be subject to the sharing limitations for pre-membership medical conditions.

Newborns

Newborns whose birth is related to an eligible maternity sharing request must be added to the household membership by the parent within 30 days of birth. In the case of a membership tier change, the monthly contribution amount will automatically be adjusted for the next contribution. If the parent does not sign-up their newborn within 30 days, any conditions present at birth or that occur before the child’s membership start date will be considered pre-membership medical conditions.

If a parent wishes to add a newborn who was not born in connection with an eligible maternity sharing request, the parent must submit a membership application form for the baby. The newborn’s membership start date can be no sooner than seven days after delivery.
Any genetic conditions or complications for newborns not born in connection with an eligible maternity sharing request are considered pre-membership medical conditions and subject to the same limitations as defined in the Pre-Membership Medical Conditions section.

Adoption

Zion HealthShare considers adopted children the same as biological children. Any physical conditions the adoptive parents are aware of 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 as defined in the Pre-Membership Medical Conditions section. Adopted children cannot be added to a Zion HealthShare membership prior to birth.

Grandchildren

A grandchild (or grandchildren) may be included as part of their grandparent’s membership under 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 group, agency, or person responsible for the grandchild’s medical needs.

Tobacco Users

Zion HealthShare members, or 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 member, or one or more members within a household, who has used any tobacco product one or more times within the past year is considered a tobacco user. Tobacco products include, but are not limited to, cigarettes, cigars, chewing tobacco, snuff, pipe tobacco, and inhaled products through vape, hookah, and similar delivery devices. Smoked cannabis products are considered tobacco for the purposes of the tobacco surcharge.

Please refer to the Tobacco Users Over 50 section.

Sharing Requests

Sharing requests are submitted on a per member, per medical need basis. A medical need is the reason for which a member submits a sharing request. This includes, but is not limited to, preventive visits, maternity, an accident, or a serious medical incident. Each medical need may result in medical expenses 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 a sharing request. Once their sharing request is open, the member must submit original, itemized bills for the medical expense within six months of treatment. Bills submitted more than six months after the date of service may be considered ineligible for sharing. There is no lifetime limit on the number of eligible expenses that may be shared.

Determination of Sharing Request

Expenses related to the same medical need, whether expenses for a single incident or separate incidents, will be shared as one sharing request.

Maximum Shareable Amounts

There is no annual or lifetime maximum for any member or membership household. However, some expenses may be subject to limitations according to these Member Guidelines. Zion HealthShare has a systematic way to handle large sharing requests and has budgeted to account for them.

Insurance, Third-Party Administrators, or Government Assistance Plans

In the event that a Zion HealthShare member is also covered by any relevant insurers, third-party administrators, or government assistance plans, and a medical need arises, the member’s insurance, third-party administrator, or government assistance plan shall be primarily responsible for the payment of the member’s medical expenses.

Members must submit a sharing request within six months of the medical need informing Zion HealthShare of their coverage by insurance, third-party administrator, or government assistance plan, upon which the insurance, third-party administrator, or government assistance plan will be primarily responsible for the payment of the member’s medical expenses. Upon final payment by the primary insurance, third-party administrator, or government assistance plan, Zion HealthShare will review remaining expenses for eligibility for sharing.

Failure to disclose coverage with an insurance, third-party administrator, or government assistance plan may result in ineligibility for sharing. This includes, but is not limited to, any form of coverage through a non-member spouse, family member, employer, or government entity. If you have primary insurance coverage, Zion HealthShare will be the secondary payor, and some expenses not covered by insurance may be shareable.
Exceptions may be made for maternity sharing requests. Contact Zion HealthShare prior to your provider visit.

Appeals

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

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

To file an appeal, send the medical evidence, a written explanation, and any other supporting documentation to needs@zionhealthshare.org.

The Initial Unshareable Amount (IUA)

The initial unshareable amount, or IUA, is the amount a member must pay before expenses related to a medical need become shareable with the medical cost sharing community. We have three membership IUA options: $1,000, $2,500, and $5,000.

After the IUA is met, additional eligible medical expenses are shareable with the Zion HealthShare community. There is no annual or lifetime limit on eligible expenses. Members do not need to pay another IUA for any given sharing request until they are symptom free for 12 months. Additionally, members will not be responsible for more than three IUAs in a rolling 12-month period.

Changing IUA Amount

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 sharing requests other than those resulting from an accident.

Multiple Sharing Requests in a 12-Month Period

We provide a safeguard for households that experience more than three shareable medical needs in a 12-month period. If a household has paid three IUAs in a 12-month period, any additional shareable expenses of $500 or more will be shared in full with no IUA responsibility.

Submission of Sharing Requests

We strive to share medical expenses in a timely, accurate manner. To do this, it is crucial for members to submit sharing requests correctly and include all required documentation.

Submitting a Sharing Request

Sharing requests should be submitted through the Member Portal, as soon as possible. Most nonemergency sharing requests, such as surgical procedures, should be submitted prior to the date of service.

Members may contact Zion HealthShare directly during business hours for help with this process.

Contact the Member Care team:
·       888-920-9466
·       needs@zionhealthshare.org

The Medical Advocacy service is complimentary to all Zion HealthShare members. Our team of experts is here to help members find providers and facilities. We can help members obtain self-pay discounts and pay ahead of time for eligible expenses.

Contact the Medical Advocacy team:
·       888-399-0017
·       advocacy@zionhealthshare.org

Required Documentation & Time for Providing Documentation

In order to be eligible for sharing, sharing requests and each itemized bill and statement must be submitted within six months of the date of service. The IUA must also be paid within six months to be considered for sharing. When submitting a sharing request, members should submit any documentation received from their provider. Zion HealthShare may request additional documents that may be required throughout the sharing request process. Document types can include, but are not limited to, receipts, proofs of payment, itemized bills and statements.

Original, itemized bills and statements should be submitted promptly to Zion HealthShare along with the sharing request form for us to process the sharing request as soon as possible.

Please reference all applicable guidelines to determine if there are other document requirements or time limits.

Meeting the IUA

Medical expenses are only shareable after members have met their IUA. Members should provide documentation to Zion HealthShare of all payments that may contribute toward the member’s IUA.

The IUA must be paid within six months of the date of service or bills may become ineligible for sharing. Consideration will be given for situations where the cost of treatment has not exceeded the IUA after six months for certain sharing requests. Members must communicate with their Member Needs team representative about a timeline for IUA payment.

Paying at the Time of Service

Zion HealthShare is not insurance, so members should tell their provider they are an uninsured, self-pay patient. That way, members can obtain self-pay discounts on services, which allows us to keep membership contributions low. Members should obtain itemized bills and receipts to request payment or reimbursement from Zion HealthShare. In some cases, prepayment may be an option.

Contact our Medical Advocacy team before receiving medical treatment for prompt payment at the time of service.

Requesting Discounts

Members have options for sharing prior to, at the time of, or after medical services are rendered. For all purposes, members should present as self-pay patients and communicate costs and discounts as soon as possible to Zion HealthShare.

Pre-Membership Medical Conditions

To keep membership contributions low for all members, we implement a waiting period for sharing of medical conditions that existed prior to a member’s membership start date. We call such medical conditions: pre-membership medical conditions. This section defines pre-membership medical conditions and outlines related sharing limitations.

Definition of Pre-Membership Medical Conditions

A pre-membership medical condition is any illness or injury for which a person has
·       been examined,
·       been diagnosed,
·       taken medication,
·       had symptoms, or
·       received medical treatment
within the 24 months prior to their membership start date. Sharing requests related to pre-membership medical conditions are only shareable if the condition was regarded as cured and did not require treatment or present symptoms for 24 months prior to the membership start date.

Pre-Membership Medical Conditions Phase-In Period

Pre-membership medical conditions have a phase-in period wherein sharing is limited. Starting from the membership start date, there is a one-year waiting period before pre-membership medical conditions are shareable. After the waiting period, the shareable amount increases with each membership year.

Shareable amounts for pre-membership medical conditions:
·       Year One: $0 (waiting period)
·       Year Two: $25,000 maximum per sharing request
·       Year Three: $50,000 maximum per sharing request
·       Year Four: $125,000 maximum per sharing request
After four years of membership, expenses related to pre-membership medical conditions will be shareable up to a maximum of $125,000 in a 12-month period. The shareable maximum resets each membership year.

Please Note: pre-membership medical conditions may still qualify for sharing through the Additional Giving fund.

Exceptions for High Blood Pressure, High Cholesterol, & Diabetes

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

Preventive Services

Zion HealthShare shares in specific preventive services with the Direct Membership or with the additional Preventive Sharing service added to the Essential Membership. Preventive sharing is not subject to the IUA.

Zion HealthShare references the following resources regarding preventive sharing:
· US Preventive Services Task Force
· American Cancer Society
· Centers for Disease Control (CDC) and Prevention Guidelines
· American Academy of Pediatrics
· American Academy of Family Physicians

See the Preventive Sharing Guide for more details.

Annual Provider Visit

Sharing for an annual provider visit is available upon membership start date and every 12 months from the shareable visit date. Sharing is limited to the cost of the office visit only, up to $175. Pap smears are considered shareable only when performed during the annual provider visit. Any additional services provided during the visit will be considered the member’s responsibility, including X-rays, lab/blood work, and other services.

For these services, members may seek lower cost options by presenting themselves as self-pay patients. Members should take advantage of the Medical Advocacy service as it is a complimentary resource to help them locate low-cost facilities.

Colonoscopies

Sharing for a screening colonoscopy is available every 10 years beginning at the age of 45 and after six months of continuous membership. Sharing is limited to $5,000 for the screening colonoscopy, anesthesia, diagnostic testing, biopsies, and pathology performed as a part of the screening. Any additional costs, services, or follow-ups will be the member’s responsibility. For high-risk members under 45, this service may be shareable with prior written approval from Zion HealthShare.

All other colonoscopies are not shareable as a preventive service but may be considered for sharing as a separate sharing request dependent upon the reason and only with prior written approval from Zion HealthShare. All non-preventive colonoscopies are subject to the IUA.

Mammograms

Sharing for a mammogram is available after six months of continuous membership and every year beginning at the age of 40. Sharing is limited to $600 for a 2D or 3D mammogram. The exam, appointment, and evaluation of imaging performed as a part of the screening will count toward the $600 limit. Any additional services provided will be the member’s responsibility. For high-risk members under the age of 40 this service may be considered for sharing with prior written approval from Zion HealthShare.

If the finding of the screening mammogram warrants an ultrasound, Zion HealthShare will consider sharing in the cost.

All other mammograms are not shareable as a preventive service but may be considered for sharing as a separate sharing request dependent upon the reason and only with prior written approval from Zion HealthShare. All non-preventive mammograms are subject to the IUA.

Youth Immunizations

Sharing for youth immunizations is available upon membership start date for members born in connection with an eligible maternity sharing request, and after six months of continuous membership for all other members up to the age of 18.

Sharing is limited for each immunization dose as outlined below:
·       HPV (Human Papilloma Virus) – $254
·       Men (Meningococcal) – $202
·       PCV (Pneumococcal) – $227
·       RV (Rotavirus Immunization) – $131
·       IPV (Inactivated Polio Immunization) – $39
·       HIB (Haemophilus Influenza Type B) – $29
·       Hep A (Hepatitis A) – $36
·       Hep B (Hepatitis B) – $27
·       VAR (Varicella) – $151
·       DTaP (Diphtheria, Tetanus, acellular pertussis) – $35
·       Tdap (Tetanus, Diphtheria, acellular pertussis) – $35
·       MMR (Measles, Mumps, Rubella) – $251

Download the Immunization Guide here.

Well Child Visits

Sharing for well child visits is available upon membership start date for members born in connection with an eligible maternity sharing request and after six months of continuous membership for all other members. Sharing is limited to $175 for the office visit costs, and associated immunizations are limited as outlined in the Youth Immunizations section.
Qualifying visits are for children at the following ages:
·       Birth
·       1 Month
·       2 Months
·       4 Months
·       6 Months
·       9 Months
·       12 Months
·       15 Months
·       18 Months
·       30 Months
·       36 Months

Additional Giving

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

All members who adhere to the Principles of Membership and follow the Member Guidelines are eligible to apply for assistance through the Additional Giving fund via an Additional Giving sharing request. Members may apply when they have an ineligible sharing request.

Guidelines for Additional Giving

Sharing requests that do not meet the Member Guidelines may be eligible for sharing through the Additional Giving fund.
·       Members and other contributors may give additional funds to share with the community or give toward a specific sharing request.
·       Members are encouraged to share out of their surplus.
·       Members looking to request sharing from the Additional Giving fund must still meet their IUA before the sharing request becomes eligible for sharing.
·       Members who apply for sharing from the Additional Giving fund may only have part of their costs shared.

End Of Life Assistance

If a member, or a member’s dependent, dies after one year of uninterrupted membership,
we will provide financial assistance to the surviving family. Our community will provide assistance after we receive a copy of the death certificate.

Financial assistance will be provided to the 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

Disclaimer

Zion HealthShare is not an insurance company. Neither this publication nor membership in Zion HealthShare are issued or offered by an insurance company. The purpose of the Member Guidelines is to help members understand and identify medical needs that may qualify for member sharing and the process by which member-to-member sharing is facilitated. The Member Guidelines are not for the purpose of defining the amounts that Zion HealthShare community will reimburse or share into. While the Zion HealthShare community has shared in all eligible member sharing requests to date, membership does not guarantee or promise that all eligible sharing requests will be shared. Rather, membership in the Zion HealthShare community merely guarantees the opportunity for members to share the financial burden in another member’s time of need. The financial assistance members receive will come from other members’ monthly contributions and not from Zion HealthShare.

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

Click here to see historical Member Guidelines.

Member Guidelines

Member Guidelines

Preventive Sharing Guide

Maternity Guide

Sharing Request Guide

IUA Guide

HealthShare Beginnings

Our Mission

Principles of Membership

Principles of Membership

Membership Eligibility

Membership Requirements

Sharing Requests

The Initial Unshareable Amount (IUA)

Submission of Sharing Requests

Pre-Membership Medical Conditions

Medical Expenses Eligible for Sharing

Medical Expenses Ineligible for Sharing

Preventive Services

Maternity Sharing Requests

Additional Giving

End Of Life Assistance

Disclaimer