Sharing Guidelines

Foundational Principles

We believe the following Biblical principles are basic to the life of every believer; therefore foundational to our health care sharing ministry:

Membership Requirements

To become a member you must meet all the requirements of this section and submit an application, including a church leader verification. As long as you continue to meet these requirements and fulfill all membership responsibilities, your membership will continue.

We believe the following membership requirements benefit all members by being Scriptural, and also by minimizing medical risks and costs, ensuring proper accountability, and encouraging good health practices. REDEEM HealthShare retains the discretion to remove from membership any member whose behavior violates Biblical standards such that they may bring the ministry into disrepute.

A. Statement of Faith and Lifestyle Requirements

1. Be a professing Christian living by Biblical principles. Every adult on the membership must affirm the following member Statement of Faith: I believe in the triune God of the Bible. He is one God Who is revealed in three distinct Persons—God the Father, God the Son, and God the Holy Spirit.
   GEN 1:26 | LUKE 1:35, 3:21-22 | 2 COR 13:14 | MATT 28:18-20

   I believe Jesus Christ was God in the flesh and continues to be such even after His resurrection—fully God and fully man. He was born of a virgin, lived a sinless life, died on the cross to pay the penalty for our sins, was bodily resurrected on the third day, and now is seated in the heavens at the right hand of God the Father.
   ISA 7:14, 9:6 | MATT 1:22-23, 26:64 | MARK 16:19 | LUKE 24:38-40 | JOHN 1:1-2, 1:14, 1:29, 2:18-21, 5:18, 8:46 | ACTS 2:32-33 | 1 COR 15:3-4, 15:20-21 | 2 COR 5:21 | COL 1:15-20, 2:9 | HEB 1:1-4, 4:14-15, 7:26, 9:11-14, 10:10-12 | 1 PETER 2:22-24 | 1 JOHN 3:5

   I believe that all people have sinned and fallen short of God's glory and can be saved from eternal death only through faith in Jesus Christ, Whose atoning death and resurrection secure for us eternal life.
   JER 17:9 | JOHN 3:3, 14:6, 20:30-31 | ROM 3:9-11, 3:23, 5:12-21, 10:8-13 | EPH 2:8-9

2. As a community of Christians helping other Christians with their medical bills, every adult on a membership must attend a Biblical, Christian church regularly (at least three out of four weeks per month that your health or weather permits). If it is not possible for you to regularly attend a Biblical, Christian church, please submit a letter giving the details. HEB 10:25 Fellowships, churches, temples, wards, and denominations that fall outside of Biblical, Christian faith—such as the Church of Scientology, Unitarian, Jehovah's Witnesses, and The Church of Jesus Christ of Latter-day Saints— do not qualify for the church attendance requirement.

3. Believe you are to bear one another's burdens.
   GAL 6:2 | PHIL 2:4

4. You believe that your body is a temple of the Holy Spirit and that abusing any substance is sin. Empowered by the indwelling Holy Spirit, you are committed to living a holy and consecrated life in which you abstain from tobacco use (a rare celebratory cigar or pipe is allowed), do not abuse any legal or prescribed substance, and do abstain from illegal drugs and recreational use of marijuana.
   ROM 13:1 | 1 COR 6:12

5. You believe that your body is a temple of the Holy Spirit and that drinking to drunkenness is sin. Empowered by the indwelling Holy Spirit, you are committed to living a holy and consecrated life in which you limit consumption of alcohol to moderate amounts and don't drink to drunkenness or cause another brother or sister in Christ to stumble.
   EPH 5:18

6. You believe that your body is a temple of the Holy Spirit and that any sexual activity outside traditional Biblical marriage as designed by God between one biological man and one biological woman is sin. Empowered by the indwelling Holy Spirit, you are committed to living a holy and consecrated life in which you abstain from any such activity.
   GEN 1:27, 2:24 | MATT 19:5 | 1 COR 6:18

7. Agree to practice good health measures in accordance with the principle that your body is the temple of the Holy Spirit.
   1 COR 6:19-20

8. Keep your membership active by ensuring that your monthly share is deposited into your sharing account each month through Click to Share. A notice will be given to members who are late in sending shares, and they will lose eligibility to have their own needs shared until the issue has been corrected. If financial need is the cause of these problems, assistance may be available through the Sponsorship Program (Section V.C).
   LUKE 16:10

9. Agree that when you have a dispute with a fellow Christian, and your fellow Christian is willing to submit that dispute to fellow believers for resolution, you are not to sue each other in the civil courts or other government agencies, (Section XII). A person initiating a legal proceeding against REDEEM would disqualify himself from membership.
   1 COR 6:1-8

10. Submit your Membership Continuation Agreement each year, confirming that you are still meeting the Membership requirements.
    PROV 10:9

11. Have someone to whom you are accountable (pastor, elder, church official, small group leader, accountability partner, etc.) sign a Church Leader Verification form confirming that you meet the above requirements.
    HEB 13:17

12. You will be required to agree to these requirements when you apply for membership and provide background information, including your date of birth. Annually, you will need to reconfirm that you still meet these requirements along with a signed Church Leader Verification form.

13. Non-U.S. Citizens: The following individual(s) can join REDEEM HealthShare: Those who possess a U.S.-issued Social Security Number and a valid Identification Card issued by a U.S. government agency. Those who possess a U.S.-issued Individual Taxpayer Identification Number (ITIN) and who also have a government-issued Identification Card issued by Mexico, Canada, Guatemala, or the United States and who have a United States mailing address.

If at any time you no longer meet all of these membership requirements, you must notify REDEEM HealthShare immediately, and your membership and all privileges will be suspended unless otherwise indicated.

Your health status has no effect on your eligibility for membership. However, there are limitations on the sharing of needs for some conditions that existed before membership. Other needs in which members share have specific requirements. For a detailed explanation of the types of needs that are shared or not shared by the members, see the shareable needs Guidelines (Section III).

To be eligible to have a need shared, a member must be meeting all of the requirements of membership including being current with all shares, and the need must not be caused by conduct inconsistent with membership requirements.

B. Family Members Defined

A membership in REDEEM™ HealthShare Ministry is limited to members of the same nuclear family. Nuclear family includes only husband, wife, and children, but can include grandchildren in the circumstances described in I.B.5.

Children 18 and over must verify that they meet the member requirements by signing an application form.

1. Spouse

   Spouse means a legally married person. It can be a person's lawfully married husband or wife. Marriage is defined as being between one biologically-born man and one biologically-born woman.

2. Adult Children (Age 18 and over)

   Your single children from age 18 up to and including age 25 may be on your membership if they are living at home (which includes while away at school full time).

   A child may be considered disabled and remain on a family membership after turning 26 if the child is receiving more than 50% financial support from their parents and qualifies as a dependent on their parent's federal tax return. Contact your Member Services team before the date they turn 26 if you wish to apply for this status

3. Newborn

   A newborn, whose addition to the membership will increase the monthly share amount, will be included within the membership retroactive to the date of birth, as long as at least one parent was a member as of the baby's birth and you notify REDEEM HealthShare to add him to the membership no later than 30 days after the birth; otherwise, the effective membership date will be no earlier than the date of notification to REDEEM HealthShare. REDEEM HealthShare should be notified as soon as possible to add subsequent newborn children to the membership. Please be aware that there are specific Guidelines addressing sharing needs for a newborn.

4. Adoption

   Adopted, unmarried children are considered members of the family the same as biological children.

5. Grandchildren

   Grandchildren may be included as part of their grandparents' membership if they meet all of the following criteria:

   1. They live permanently with their grandparents (their residence), and

   2. The grandparents have legal custody, or the grandchild is the child of a minor, and

   3. They meet the eligibility Guidelines for children, and

   4. They have no other agency, person, or group responsible for their medical bills.

6. Dependent Child(ren)

   Guardian memberships are allowed. The guardian must be 18+ to manage the membership on behalf of the minors.

C. Inactivation of Membership

1. Voluntary Inactivation. Members can voluntarily inactivate their membership in good standing at any time which shall take effect at the end of any month.

2. Involuntary Inactivation

Membership will be inactivated if:

• The member fails to fund their share wallet for 60 days.
• The member fails to complete the click-to-share requirement for 60 days.
• The Member fails to resolve Know Your Customer (KYC) issues within 60 days.

Notice Periods

30 Days Notice: After 30 days of non-compliance, members will receive a notice informing them of their ineligibility for sharing until the issue is resolved. Membership will be suspended at this point.

45 Days Notice: After 45 days of non-compliance, members will receive a second notice.

60 Days Notice: After 60 days of non-compliance, the membership will be inactivated, effective from the date the member should have funded the share wallet or completed the click-to-share requirement.

D. Reactivation of Membership

1. Memberships that have been inactivated involuntarily can only be reactivated after all back-shares have been paid.
2. Only eligible bills with Dates of Service (DoS) prior to the inactivation date will be shared.
3. Bills for conditions incurred or discovered after inactivation will be considered pre-existing and will not be shared.

E. Changing Programs: Circumstances for Changing AUA Level or Program

1. Members are allowed to change their Annual Unshared Amount (AUA) level or program within 30 days of the following circumstances, with the effective date being the date of the event:

   • Membership Anniversary
   • Change in Marital Status
   • Change in Child/Dependents
   • Birth/Adoption
   • Age Out: Changes can be made when a dependent ages out of eligibility.
   • Loss of Spouse
   • Loss of Employment

2. When switching from Essential to Enhanced OR when switching from a higher AUA to a lower AUA, the 12-month waiting period for the conditions and treatments listed in sections 3.iii, iv resets.

3. Switching Fee: Changing your program or AUA level requires a switching fee of $100. You can choose any future month for your switch to occur and the $100 switching fee will be applied within one to two months after the switch is effective.

4. Resetting AUA: Changing your program or AUA level will reset the AUA for the year.

5. Adding or Removing Members:

   Eligibility: You can add or remove members from your membership at any time.

   Share Amount Adjustment: If the addition or removal of a member impacts your share amount, the change will be reflected in your next Share Notice.

Program Details

A. Healthcare Sharing

REDEEM™ HealthShare Ministry is a not-for-profit healthcare sharing ministry that facilitates direct member-to-member cost-sharing.

Healthcare sharing is a voluntary arrangement that unites individuals and families in the REDEEM HealthShare community through acts of mutual support and love, reflecting the early Christian church's commitment to caring for one another (Acts 2:44-45). Guided by our shared faith and Biblical principles, we come together to bear each other's burdens and demonstrate the love of Christ in practical ways.

The program is designed for sharing of medical expenses related to conditions resulting from a new illness, injury, or accident.

To participate, members voluntarily contribute a monthly share amount according to the age of the oldest member in the household, the sharing level chosen, and the number of participants on the  membership.

B. No Member or REDEEM HealthShare Liability

REDEEM HealthShare is not insurance. REDEEM HealthShare is a Healthcare Sharing Ministry, as outlined in the Patient Protection and Affordable Care Act and was created to facilitate the sharing of medical bills and expenses among members, one with another, according to these Guidelines, at REDEEM HealthShare’s reasonable discretion. REDEEM HealthShare is not liable for the payment of a member’s medical bill. If sharing occurs, the shared medical bills are paid by the member that incurred the bill from other members’ share contributions only, not from funds of REDEEM HealthShare itself.

REDEEM HEALTHSHARE IS NOT AN INSURANCE COMPANY. HEALTHCARE SHARING IS NOT INSURANCE OR A CONTRACT FOR INSURANCE. THE PAYMENT OF MEDICAL BILLS BY MEMBERS THROUGH REDEEM HealthShare HEALTHSHARE OR OTHERWISE IS NOT GUARANTEED IN ANY WAY.

There is no transfer of risk from a member to REDEEM HealthShare or from a member to other members, and there is not a contract of indemnity between REDEEM HealthShare and any member or between the members themselves

C. Guidelines Govern

These Guidelines explain the program requirements and govern the sharing of medical bills. The Guidelines in effect at the time of service govern the program, not the Guidelines in effect when a member joins or changes to the Guidelines that occurred after the time of service. The Guidelines are available online at http://redeemhealthshare.org and in your Member Center.

D. Changes to the Guidelines

Changes to the Guidelines can be made at any time by REDEEM HealthShare Ministry Executive Team. Members will be notified of the changes, and a history of changes will be available in the Member Center for 2 years from the date of the change.

E. Key Healthcare Sharing Terms

1. Annual Unshared Amount (AUA)

The Annual Unshared Amount (AUA) is the dollar amount a Household must pay toward their own Eligible Medical Bills during a 12-month period before their Eligible Medical Bills can be published and shared by the membership.

All Eligible Medical Bills are subject to the AUA and co-share (co-share for REDEEM Essential memberships only) except the annual routine wellness visit and preventive examinations as detailed in the Guidelines.

The AUA 12-month period begins on the Membership Date.

The AUA resets on the anniversary of your Membership Date. Your Membership Date is the date that your membership in the REDEEM HealthShare Ministry program started.

A member can change their AUA amount on the anniversary of their Membership Date. A switching fee may apply as per the Guidelines.

2. Co-Share

Essential Members: Once the AUA is met, the ministry will share 80% of eligible medical bills. The remaining 20% (the Co-share amount) will be paid by the member up to the annual Co-share Limit. . 

3. Co-Share Limit

There is a co-share limit per household per year. The co-share amount is paid by the member on each eligible bill until the Co-Share Limit has been met.  The Co-share limit will reset on the Membership Date or on the effective date of any AUA reset occuring during the Membership Year.  

4. Proration

If an eligible bill is not funded by members’ sharing in that bill within 90 days of entering the normal sharing queue, then that bill is removed from the normal sharing queue and will be handled through the Member Assistance Fund. Any money currently in the bill account will be sent to the provider as a partial payment.

Eligible for Sharing

Eligible bills must meet the following criteria:

Condition, Injury, or Illness:

The bill must be for a condition, injury, or illness that developed after the start of the membership.

Only new bills for non-pre-existing conditions with Dates of Service (DoS) after the membership start date are eligible for sharing.

Bills not related to a condition, injury, or Illness such as preventive and routine wellness visits are only shareable in REDEEM Enhanced per the guidelines that govern such medical costs.

A. Incurred Services or Qualifying Estimates:

In most instances the bill must be for actual services incurred. However, for maternity or in cases where significant savings can be achieved, the submission of bill estimates are acceptable.

Not Listed as Non-Eligible:

The bill must not be included in the "not eligible for sharing" category.

Submission Timeframe:

The bill must be submitted within 12 months of the Date of Service (DoS).

Most medical providers are willing to submit their bills electronically directly via the membership card’s EDI number. However, in the event that a member must submit a bill for processing and/or reimbursement, it must be submitted using the online submission tool. Bills submitted by the provider must follow standard healthcare industry submission and coding guidelines. This is necessary for bills to be considered for sharing.

• When submitting a medical bill for processing, the member is responsible for obtaining all information needed for processing per the form available online.
  
  

B. Sharing Limits

First 90 Days of Membership: For the first 90 days, only bills resulting from injury, acute illness, or accident are eligible for sharing, with a cap of $50,000.

Non-Shareable Conditions in First Membership Year: The following conditions are not shareable for the first 12 months of membership, except through FlexShare if that option is selected:

• Arthritis

• Autoimmune disorders

• Bone spurs

• Cataracts

• Glaucoma

• Lyme disease

• Macular degeneration

• Varicose veins

• Sleep apnea (including CPAP)

Non-Shareable Treatments in First Membership Year: The following treatments are not shareable for the first 12 months of membership, except through FlexShare if that option is selected:

• Allergy treatments

• Hormone therapy

• Joint replacement

• Liposuction

• Prosthetics

Annual Sharing Cap:

Each member in Essential has an annual sharing cap of $1 million.

Each member in Enhanced has an annual sharing cap of $2 million.

Lifetime Limits:

There are no lifetime limits on sharing, except for specified items. 

Right to Reject Charges:

REDEEM HealthShare reserves the right to reject unreasonable, excessive, and duplicate charges.

C. Permitted Sharing Levels

“Permitted Sharing Level(s)” means charges for Medical Care, which is Medically Necessary for the care and treatment of Illness or Injury, but only to the extent that the fees charged, therefore are within all applicable limitations and restrictions established -in the REDEEM HealthShare Guidelines (the “Guidelines”) including, but not limited to, the following:

•    Hospitals (both inpatient and outpatient services), Ambulatory Surgery Centers, and Independent Facilities: The Permitted Sharing Level for Medical Care established by the Guidelines shall be based upon the average of 150% of the Medicare Allowable Amount for the Medical Care included in the Guidelines and 135% of the Cost of the Medical Care included in the Guidelines; provided, however, that any such Permitted Sharing Level based on the Cost of the Medical Care included in the Guidelines shall be limited to an amount not to exceed 175% of the Medicare Allowable Amount or the amount of Usual, Customary and Reasonable Fees for the Medical Care included in the Guidelines.

 
• Professional Services. The Permitted Sharing Levels for Professional Services shall be determined based upon the chart for the professional service identified. This chart is available upon request.

o Dialysis Services. The Permitted Sharing Level for dialysis services (which shall include dialysis, facility services, supplies and medications provided during treatment) shall be determined by review of the Medicare Allowable Amount for the billing Hospital or Physician in light of clinical considerations pertinent to the patient being treated.

• Medical Care Provided Under Direct Contract. The Permitted Sharing Levels for Medical Care provided by Directly Contracted Hospitals or Physicians will be the rates or fees established under the applicable contract; provided, however, that the amounts of such rates and fees shall be presumed to be Usual, Customary and Reasonable only to the extent that they do not include otherwise Improper Balances, which charges shall be outside of the Permitted Sharing Levels.

In the event that the Permitted Sharing Level exceeds the actual charge billed for the treatment, service or supply in question, sharing and payments to providers will be based on the actual billed charge. The Permitted Sharing Level for Medical Care will not include charges related to Unbundling, Errors, Unclear Description or Misidentification.

Eligible needs will be approved for sharing when medically necessary. Medically Necessary, which is defined as health care
services that are clinically appropriate in terms of type, frequency, extent, site and duration for the diagnosis or treatment of the member’s sickness or injury, and ordered by a Physician exercising prudent clinical judgment for the purposes of evaluation, diagnosis or treatment of that member’s sickness or injury. The Medically Necessary setting and level of service is that which, considering the member’s medical symptoms and conditions, cannot be provided in a less intensive medical setting. Such services, to be considered Medically Necessary must be no more costly than alternative interventions, including no intervention and are at least as likely to produce equivalent therapeutic or diagnostic results without adversely affecting the member’s medical condition.

• It must not be maintenance therapy or maintenance treatment;

• Its purpose must be to restore health;

• It must not be primarily custodial in nature;

• It must not be a listed item or treatment not allowed for reimbursement by CMS (Medicare); and

• REDEEM reserves the right to incorporate CMS (Medicare) guidelines in effect on the date of treatment as additional criteria
for determination of Medical Necessity and/or eligibility of a Need.

• The mere fact that the service is furnished, prescribed or approved by a Physician does not mean that it is “Medically Necessary.”

• The determination of whether a service, supply, or treatment is or is not Medically Necessary may include findings of the American Medical Association and REDEEM’s own medical advisors.

Off-label Drug use is considered Medically Necessary when all of the following conditions are met:

• The Drug is approved by the FDA;

• The prescribed Drug use is supported by one of the following standard reference sources:

o DRUGDEX;

o The American Hospital Formulary Service Drug Information;

o Medicare approved Compendia; or

o Scientific evidence is supported in well- designed clinical trials published in peer-reviewed medical journals, which demonstrate that the Drug is safe and effective for the specific condition; and

o The Drug is Medically Necessary to treat the specific condition, including life-threatening conditions or chronic and seriously debilitating conditions.

Provider Appeals
A Provider has 180 days from the date a bill was processed to appeal a bill sharing decision. After completion of the initial review, if the Provider still disagrees with the bill sharing decision, the Provider then has 60 days from the date of the original decision to request a second appeal.

Prepayment
When pre-payment is requested, REDEEM will make every effort to negotiate with the provider/facility to ensure that we obtain a rate that is consistent with our permitted sharing level. If the provider/facility is unable to provide a rate that meets our permitted sharing level, REDEEM will make every effort to find a provider/facility whose fees are closer to our permitted sharing level. The member can choose to see the provider of their choosing, but if the rate is more than our permitted sharing level, then prepayment and sharing will be limited to 200% of the CMS rate, and the member will be responsible for the remaining balance.

Any bills paid in full by the member will be shared based off what was paid.

D. Approved Sharing

To be eligible for sharing, testing and treatment must be submitted on a CMS 1500 form or a UB and IB form or uploaded through the online member bill submission tool, and ordered by a:

• Medical Doctor (M.D.)

• Doctor of Osteopathy (D.O.)

• Naturopathic Doctor (N.D.)

• Nurse Practitioner (N.P. or A.P.R.N.)

• Physician’s Assistant (P.A.)

• Doctor of Podiatric Medicine (D.P.M.)

• Dentist (D.D.S. or D.M.D.)

• Midwife

• Ophthalmologist

• Chiropractor

These tests and treatments must occur at one of the following:

• Hospital

• Surgery center

• Clinic

• Doctor’s office

• Diagnostic facility

Diagnoses and treatments are to be performed in the U.S. to be eligible for sharing, except in emergencies while traveling or by previous arrangement with REDEEM HealthShare.

E. Limited Sharing

Medical bills for specific conditions might be eligible for sharing, depending on a member's Annual Unshared Amount (AUA), co-share amounts, and other applicable conditions. Refer to each category below for detailed information.

1. Pre-existing conditions: Pre-existing medical conditions are defined as conditions in which known signs, symptoms, testing, treatment, diagnosis, or use of medication occurred within 36 months prior to the member’s start date. Routine or maintenance medications are considered treatment and are included in this definition, based on medical records. Testing for the purpose of monitoring a prior resolved condition will not be counted for pre-existing conditions so long as the tests indicate the continued resolution of the issue. Any pre-existing condition known to exist at the start of membership has a three-year waiting period from the start of membership for bill sharing outside of Flexshare. After this waiting period, up to $125,000 will be shared per member per year towards pre-existing conditions. In the sixth year of membership, this limit increases to $500,000

a. Adoption: Any physical condition of which the adopting parents had reason to be aware that the adopted child had prior to the adopting parents being legally responsible for the child’s expenses, or prior to his effective date within his parents’ membership, will be considered a pre-existing condition

b. Exceptions:

1. 1. 1. Heart and Cancer Conditions: Bills for pre-existing heart and cancer conditions are subject to a five-year waiting period from time of membership. After this waiting period, the sharing limits in III.D.1 will apply. This waiting period will not apply to a new heart or cancer condition that occurs after membership begins.

      2. Type 1 Diabetes: Bills for pre-existing type 1 diabetes are not eligible for sharing.

      3. High Blood Pressure: Bills for pre-existing high blood pressure can be shared provided the member has not received hospital treatment for high blood pressure in the last five years, and the condition is controlled through medication or diet.

      4. Elevated Cholesterol: Elevated cholesterol alone is not considered a pre-existing condition, even if a statin is prescribed. However, if the statin is prescribed for a pre-existing condition such as arteriosclerosis, it will be considered pre-existing.

c. FlexShare Submission: Pre-existing conditions can be submitted for FlexShare once the initial six-month waiting period for Flexshare has elapsed.

2. Maternity and Newborns

a. Due Date Requirements: Maternity expenses are eligible for memberships where two or more members (one of whom must be the mother) have been active for at least 12 months before the estimated due date, based on medical records. This 12-month waiting period also restarts after a switch from
Essential to Enhanced or to a lower AUA.

b. Services Eligible for Sharing

1. 1. Antepartum care

   2. Labor and delivery

   3. Postpartum care

   4. Well-baby visits for the first three years are sharable if the membership has been part of REDEEM Enhanced for 12 months prior to the delivery date. These services are not subject to the AUA or co-share amounts.

c. Adding Newborns to Membership
The baby must be added to the membership within 30 days of delivery to be considered a member from birth.

d. Birth Defects and Conditions
Any known birth defects or conditions in the baby from a preexisting maternity are not eligible for sharing. If birth defects or conditions are discovered after the mother
joins, these will be sharable after the AUA is met.

e. Approved Providers for Delivery
1. Medical doctor (MD)
2. Doctor of Osteopathy (DO)
3. Certified midwife

f. Ectopic Pregnancies

1. Expenses Shared—Procedures related to a ruptured fallopian tube (including postoperative recovery of the mother, follow-up care, and treatment of any complications), and, where an ectopic pregnancy is diagnosed before a rupture, all preoperative tests and consultations and expenses related to keeping the mother under medical care while determining what care should be offered for the mother and child.

2. Expenses Not Shared—Procedures directly related to the termination of a living, unborn child and/or removal of the living, unborn child from the mother due to an ectopic pregnancy are not shared (e.g. methotrexate, salpingectomy, salpingostomy), unless the removal of the child from its ectopic location was for the primary purpose of saving the life of the child or improving the health of the child.

3. Prescriptions

   a. Inpatient Prescriptions

Eligibility:

• Prescriptions administered as part of inpatient treatment are sharable.

• These are subject to the Annual Unshared Amount (AUA) and co-share amounts.

• Sharing is up to the $1 million annual maximum shareable amount.

      b. Outpatient Prescriptions

Enhanced program:

• Outpatient prescriptions are sharable only within the Enhanced program.

• There is an annual cap of $1000 per household per year.

      c. FlexShare Submissions

All Other Prescription Costs:

• Any prescription costs not shareable under the above categories can be submitted to FlexShare.

4. Routine & Wellness Visits

Routine and wellness visits are eligible for sharing only if the member is part of the REDEEM Enhanced program.

Frequency: Each member is eligible for one routine visit per year, which includes wellness gynecological visits.

Cap: Routine visits are capped at $300 per person per year.

Routine visit costs are not subject to the Annual Unshared Amount (AUA) and co-share amounts.

5. Immunizations

Immunizations and the associated office visit are sharable for children who are members of REDEEM Enhanced from birth until two years of age. The cost of vaccinations may be shared for children who are members of REDEEM Enhanced between the ages of three and six as part of the child’s annual routine visit subject to the $300 annual per member cap. 

Immunization costs are not subject to the AUA and co-share amounts.

6. Preventative Screenings

Preventative screenings are limited to the screenings listed below. These are only eligible for sharing if the member is part of the REDEEM Enhanced program and are subject to the following conditions:

Mammograms

• One mammogram per year beginning at age 45.

• Not subject to the Annual Unshared Amount (AUA).

• Not eligible for sharing within the first 6 months of membership.

Prostate-Specific Antigen Test (PSA)

• One PSA test per year beginning at age 45.

• Not subject to the Annual Unshared Amount (AUA).

• Not eligible for sharing within the first 6 months of membership.

Colonoscopy

• One colonoscopy every 5 years per person or every 2 years for high-risk individuals (as determined by their physician), beginning at age 45.

• Cologuard (or equivalent testing) may be substituted for a scheduled colonoscopy if desired.

• Not subject to the Annual Unshared Amount (AUA)

• Not eligible for sharing within the first 6 months of membership.

7. Mental Health

Cost for involuntary commitment up to $50,000 per year is sharable and subject to AUA and co-share.

Otherwise shareable only through FlexShare.

      8. Therapies

There is a $5,000 cap per membership per year for the following therapies and treatments:
a. Vision
b. Cardiac
c. Respiratory
d. Physical therapy
e. Occupational therapy
f. Speech therapy
g. Hormone therapy
h. Injections
i. Chiropractic care

These therapies and treatments are subject to the Annual\ Unshared Amount (AUA) and co-share amounts. They must not
be for pre-existing conditions.

    9. Motor Vehicles

Medical bills incurred for injuries resulting from motorized vehicles will only be eligible for sharing after any insurance entity or other liable third party has paid their portion, provided all other Guideline requirements are met. If the member was operating the vehicle, the vehicle must not have been operated recklessly.

10.  Medical Transportation

Ground: Eligible for sharing if medically necessary in emergencies. Subject to AUA and Co-share amounts.

Air: Eligible for sharing if medically necessary in emergencies. Subject to AUA and Co-share amounts.

11.  Telemedicine

Urgent care telemedicine conducted using our approved telehealth provider is freely available through the Member Center and is not subject to the AUA and co-share. Other telehealth visits will not be eligible for sharing.

      12.  Hospice Care

Hospice care services will be shared for 90 days upon prescription by a physician or certification that the person is terminally ill. Additional 90-day periods will be shared with a renewed prescription/certification subject to the per-year dollar maximum. If the member is in our Senior Saver program, then Medicare must provide their coverage first before any noncovered portions can be shareable by Redeem members.

      13.  Skilled Nursing Facility

Skilled Nursing Facilities are shareable for up to $10,000 per person per year once AUAs have been met for a shareable condition.

F. FlexShare

FlexShare is an optional add-on feature, permitting the submission of additional items for sharing. The program provides a per membership annual allowance for eligible expenses of $1,000 for Essential and $1,500 for Enhanced. 

Members become vested in the FlexShare program after six months of membership. The annual amount resets on the member's anniversary date, and any unused balance does not carry over to the next year.

FlexShare expenses must comply with the Statement of Faith and Membership Requirements, and they must be submitted through the Member Center as a FlexShare Expense. This feature is intended to offer additional support within the stipulated annual limit and under the specified terms and conditions and is subject to the list of items not eligible for sharing.

Example Treatments Eligible for FlexShare

1. Pre-existing conditions

2. Routine and preventative care

3. Dental

4. Vaccines for members in Essential

5. Vaccines for members older than 6 in Enhanced

6. Bills related to sleep apnea.

7. Vision

8. Audiological

9. OTC medications, vitamins, supplements

10. Essential oils

11.  Primary Care Fees

12. Mental health counseling or therapy

13. Durable medical equipment

14. Prosthetics

15. Home health

16. Weight reduction

17. Gym Membership

18. Gym Equipment

19. Alternative/holistic/naturopathic treatments such as:

    1. Massage therapy

    2. Prolotherapy

    3. Acupuncture/acupressure

    4. Platelet-rich plasma

    5. Ozone injections

    6. Dry needling

    7. Disc decompression

    8. Hyperbaric treatments

    9. Softwave therapy

G. REDEEM Senior Saver

Redeem Senior Saver is for believers 65 years of age and older. It is designed to work with Medicare Parts A and B, providing a significantly lower share. In Senior Saver, Medicare Parts A and B will cover 80% of the costs of bills incurred for services that Medicare covers with Redeem members sharing the remaining 20%. Members are not required to join Senior Saver when they turn 65; they can participate in Redeem Essential or Redeem Enhanced for as long as they like.

1. Senior Saver Membership Requirements

• Seniors must have Medicare Parts A and B at the time of joining Senior Saver
  
• Members wishing to have prescriptions shared must also have Medicare Part D.
• Members may only join as individuals. Those wishing to have a “couple” or  “family” membership will need to participate in Redeem Essential or Redeem Enhanced.
• All other membership requirements in Section I apply

2. FlexShare

• The FlexShare option is available to members of Senior Saver.
• The FlexShare annual limit for each Senior Saver membership is $1,000

3. What is Shareable

• Items that Medicare Parts A and B cover will also be shareable with Redeem members after Medicare’s coverage has been applied and the $500 AUA has been reached.
• Prescriptions can be shared only for Senior Saver members with Medicare Part D after Medicare’s coverage has been applied and the $500 AUA has been reached.
• The exceptions to the above would be any bill related to services mentioned in section III.G (Not Eligible for Sharing).

H. Not Eligible for Sharing

Treatment that is in violation of the Statement of Beliefs and Ethics including illness or injury arising from grossly negligent acts, use of illegal drugs, abuse of alcohol, or any illegal activity, whether or not an arrest is made, charges are filed, or a conviction results.

1. Cosmetic Surgeries with exceptions:
   1. Breast reconstruction after cancer
   2. Medically necessary breast reduction
   3. Reconstructive surgery from any injury
   4. Cleft palate
2. Infertility treatment
3. In-vitro fertilization
4. Genetic testing
5. Inpatient psychological treatment
6. Medical supplies (except in FlexShare)
7. Non-medical expenses
8. Gym memberships (except in FlexShare)
9. Bills related to an event while on active duty.
10. Bills that should be covered by Worker’s Compensation Insurance
11. Any injury or illness arising from any illegal activity.
12. Charges outside the US if they traveled to that location for the sole purpose of receiving treatment.
13. Any charges where a Third-Party is responsible.
14. Charges not submitted within the 12-month timeline from the date of service.
15. Charges for the release of medical records
16. Charges for anything relating to transsexualism, gender dysphoria, sexual reassignment or change, including medications.
17. Charges for travel or accommodations to pursue treatment at a non-local site of care unless approved by the ministry on a case-by-case basis.
18. Drug/alcohol treatment
19. Procedures or surgery that is not medically necessary
20. Prophylactic (treatment intended to prevent disease) and preventive surgery without personal history of diagnosis and a doctor’s recommendation.
21. Nutrition Services, (except in FlexShare)
22. Experimental Treatment
23. Psychotropic medication
24. Birth control
25. Abortion
26. Complications related to ineligible procedures, conditions, and diagnoses except pre-existing maternity. This includes any future-related needs.
27. Transportation to appointments
28. Additional wellness visits beyond the one allowed per membership year, (except in FlexShare).

I. Medically Necessary Treatment

Eligible needs will be approved for sharing when medically necessary, which is defined as healthcare services that are clinically appropriate in terms of type, frequency, extent, site, and duration for the diagnosis or treatment of the member’s sickness or injury and ordered by a Physician exercising prudent clinical judgment for the purposes of evaluation, diagnosis or treatment of that member’s sickness or injury.

The determination of whether a service, supply, or treatment is or is not Medically Necessary may include findings of the American Medical Association, CMS, and REDEEM HealthShare’s Administrator or medical advisors.

The mere fact that the service is furnished, prescribed, or approved by a Physician does not mean that it is “Medically Necessary.”

Conditions of Sharing

REDEEM™ HealthShare Ministry is not a Substitute for Insurance as may be Required by Law. REDEEM HealthShare is not insurance. However, REDEEM HealthShare may be used to satisfy the federal mandate that became effective January 1, 2014, requiring “applicable individuals” to maintain “minimum essential [insurance] coverage” or to satisfy a certain state requirement to maintain “minimum creditable [insurance] coverage”.

These are the only exceptions. Otherwise, members must not certify that REDEEM HealthShare is insurance to avoid purchasing insurance required by law, rule, or regulation, such as  worker’s compensation insurance.

A. Other Responsible Parties

If a member has insurance or is eligible/qualified for any insurance benefits or other health or welfare benefits, such as an employment-related health or welfare plan, worker’s compensation insurance, homeowner’s insurance, or fraternal benefits, the member is expected to take all reasonable steps to qualify for such payments and to exhaust benefits available under those resources before submitting a request for sharing.

A member can appeal bill-sharing eligibility decisions with which they disagree if he or she believes:

• the medical records were misread, or

• the Guidelines were misapplied, or

• one or more of the member’s providers incorrectly recorded their medical history.

After a review by REDEEM™, if the member disagrees with REDEEM HealthShare's decision, the member has 90 days to request a review by a Member Appeal Panel established by REDEEM HealthShare, composed of seven to thirteen members. As part of this process, the member may submit a written position statement to the Panel. A teleconference will be held wherein the Panel can ask questions of both the member and REDEEM HealthShare. A simple majority vote will carry the decision to share or not.

Membership requirement issues related to your payment of shares or your integrity (with respect to the submission and payment of medical bills) may be appealed to the Institute for Christian Conciliation as explained below. All other questions regarding whether you meet membership requirements may be appealed to the Board of Directors who make the final, non-appealable decision.

Any other issue shall be settled in accordance with the Rules of Procedure for Christian Conciliation™ of the Institute for Christian Conciliation. (Complete text of the Rules is available at ICCpeace.com or by contacting ICC Peace at info@iccpeace.com). However, if both REDEEM HealthShare and you agree, the dispute may be submitted to a randomly selected panel of members instead. In all events, you will have available the same relief as a court could grant. REDEEM HealthShare will pay all of the arbitrator’s fees and costs unless the arbitration determines there was no reasonable basis for your complaint, in which case you will be responsible for the fees and costs.

You understand that these methods shall be the sole remedy for any civil controversy or claim arising out of your relationship with SMI and expressly waive your right to file a lawsuit in any civil court against REDEEM HealthShare, its employees, members, associate members, and directors, for such disputes, except to enforce an arbitration decision obtained under Sections XII.A or XII.B. This also includes any determinations as to whether the matter in dispute comes within this arbitration agreement or can be required to be arbitrated. If an arbitration decision has been made and anyone is failing to follow that decision, then in order to enforce the arbitration award under either Sections XII.A or XII.B, the decision may be entered only in the Circuit Court of Peoria County, Illinois.

Resolving disputes within the Body of Christ is always the command of Scripture and in the interest of all our members (MATT 18:15-20; 1 COR 6). Therefore, even if REDEEM HealthShare or a member participates to some extent in a court proceeding regarding a matter in dispute, this participation will not be forfeiting the ability to later demand that the dispute be resolved by these arbitration procedures.

For all civil matters of procedure and substance regarding any dispute or claim that comes within these mediation/arbitration requirements, the laws of the State of Texas, and if applicable of the United States, shall govern.

C. Misuse of Trust and Accountability 

At all times, act with integrity. Members presenting a falsified need, using deceptive practices, or participating in another member’s misuse of trust will be dropped from membership. 

Members submitting needs further commit to work with REDEEM HealthShare staff and partners to determine if the bills are shareable, to seek fair and reasonable prices from providers, and to document amounts paid to providers. 

When an issue of possible misuse of trust by a member arises (whether or not still active or currently a member), the administrative office may seek the assistance of the member’s Christian church and provide it with the necessary information to address the issue and hold the member accountable. The member may request resolution of the question through the mediation and arbitration provisions of the Guidelines. 

Virtual Share Account

To make Healthcare Sharing convenient and efficient, REDEEM™ HealthShare Ministry utilizes a technology platform called a Virtual Share Exchange (“VSE”). The VSE enables all REDEEM HealthShare members to participate in the Healthcare Sharing process electronically, as well as to monitor the transactional activities of their individual share accounts and the community at large. Your REDEEM HealthShare membership requires that you activate your own Share Account and enable the Virtual Share Exchange to administer the sharing process on your behalf. By activating your Share Account and accepting the Virtual Share Exchange “Terms and Conditions” and Disclosures, you have given REDEEM HealthShare, and its Service Agents express permission to conduct financial transactions necessary for the administration of the program on your behalf.

A. Share Account

To participate in the REDEEM HealthShare Community, all members must activate a Share Account on the Virtual Share Exchange Platform. Your Share Account is a virtual account, and all deposited funds are received by America’s Christian Credit Union located in Glendora, CA which holds them “For the Benefit of REDEEM HealthShare Members”. The Share Account will display your account balances, sharing transaction history and other relevant information. The money in your Share Account is insured and is fully controlled by you except as described herein.

To activate your Share Account, you will be required to provide the necessary personal information to comply with U.S. Banking Regulations (e.g. “Know Your Customer” KYC). Once your information is submitted and verified, you will be required to link your Share Account to one of your External Bank Accounts, such as Bank of America or Wells Fargo. Each month, you will fund your Share Account with an EFT (electronic funds transfer) from your External Bank Account.

B. Monthly Share Notice

REDEEM HealthShare members will receive a Monthly Share Notice through the VSE Platform to inform them and remind them of the monthly amount that they are to contribute. The monthly amount that you are to contribute (your Total Share Amount Due) is based on the REDEEM HealthShare program Level that you have selected.

The amount specified in your Monthly Share Notice is transferred through an EFT drawn off your External Bank Account or a credit card. EFTs are always for the “Total Share Amount Due.” The “Total Share Amount Due” is displayed on every Monthly Share Notice, and it will include the current Monthly Share Amount, any Past Due Amounts, and any relevant Service Fees.

The Total Share Amount Due may be paid manually within the VSE Platform. You will have the ability to add, edit, and delete your Recurring EFTs, as well as your linked External Bank Account or credit card, at any time.

C. Account Management

Your Share Account is a financial account that you own and control. You will have the ability to add, edit, and delete your EFT settings, as well as your linked External Bank Account or credit card, at any time.

D. Publishing & Sharing

Participation in the REDEEM HealthShare Ministry Community is voluntary. This means that when you are selected to participate in a sharing event if you object to that particular sharing event for any reason, you may withdraw and terminate your membership during the three-day publishing period (described below) rather than participate in that sharing event.

Medical Bills that are eligible for sharing are matched, allocated, and published to the membership prior to sharing. To cooperate with regulations and safe harbor statutes, REDEEM HealthShare implements a member-to-member, or peer-to-peer (P2P), approach to sharing, which means that members share funds directly with one another, rather than drawing funds from a pool controlled by REDEEM HealthShare.

Your medical bills will be submitted to REDEEM HealthShare by your Medical Providers. REDEEM HealthShare will process all bills for eligibility per the Guidelines. Eligible bills are then submitted into the Virtual Share Exchange for sharing. Amounts Approved for Sharing are allocated to your fellow members who have been matched to share in (contribute toward payment of) your bill.

Members who have been matched to share your bill will be notified through a process called “publishing” as to the amount that will be withdrawn from their Share Account for the payment of your bill. They will also be notified as to who will be receiving their funds unless you choose the anonymous setting in your Share Account’s Sharing Permissions. Once the three-day publishing period has ended, the amount published to each member is transferred to a Virtual Bill Account for the payment of your bill.

Members who have been matched and allocated to share in another member’s medical bill may withdraw from the membership prior to the expiration of the three-day Publishing Period, in which case no funds will be transferred to the receiving member.

Because a member may refuse to share in a particular medical expense for any reason or no reason, the sharing process remains entirely voluntary for every member. However, as noted above, any sharing refusal requires withdrawal from membership before the end of the three-day Publishing Period.

E. Virtual Bill Accounts

If you have an eligible medical bill that has been approved for sharing, the VSE will create a Virtual Bill Account for the payment of that bill. Virtual Bill Accounts are unique to a specific medical bill and are linked to your Share Account. Each Virtual Bill Account is unique to a member of your household, a medical provider, and a specific bill. Amounts collected in your Virtual Bill Account(s) are restricted and are displayed as a single line-item transaction in your Share Account.

F. Provider Payments

Virtual Bill Accounts remain open until the Amount Approved for Sharing has been fully collected and transferred to your Medical Provider as payment for your bill or to you as a reimbursement. While Virtual Bill Accounts are aggregated in the transactional view of your Share Account, these funds are restricted and cannot be withdrawn from your Share Account. The transfer of funds out of your Virtual Bill Account will be displayed as a single line-item transaction in your Share Account.

G. Member Share Wallet(s)

In order to process and pay medical bills quickly, REDEEM HealthShare implements a practice called Member Share Wallet(s). REDEEM HealthShare is NOT insurance, so we do not collect and hold medical reserves in a centralized bank account. Instead, the Monthly Share Amount is set at a level to build a small balance in every member’s individual Share Account. These “Member Share Wallet(s)” enable REDEEM HealthShare to plan for the ebb and flow of medical usage and payments.