Sharing Guidelines

III. Sharing of Expenses

A. Expenses Eligible for Sharing

To be eligible for sharing a bill must meet the following criteria:

Be the Result of Condition, Injury, or Illness:

The bill must be for a condition, injury, or illness and have a Date of Service (DoS) after the membership start date.

Bills for pre-existing conditions are also shareable under certain circumstances. The guidelines for pre-existing conditions are discussed in detail in Section III.D. In every case, bills must always have a Date of Service (DoS) after the membership start date to be eligible for sharing.

Bills not related to a condition, injury, or illness—such as preventive and routine wellness visits—may only be shareable in REDEEM Enhanced (See Section III.G) or in FlexShare.

For 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 may be acceptable.

Be Not Listed as Not Eligible:

The bill must not be included in the Not Eligible for Sharing category in Section III.H.

Submission Timeframe:

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

Many medical providers are willing to submit their bills electronically directly via the Member Card EDI number. However, if a member must manually submit a bill for processing, it must be submitted using the online submission portal in the Member Center. Bills submitted by the provider must follow standard healthcare industry submission and coding guidelines. This is necessary for bills to be considered for sharing. Members should ask their provider for a Superbill, which is a common and comprehensive healthcare industry billing documentation format.

Bills must include itemized details, including:

• Name of member/patient
• Diagnosis/ICD10 Codes
• Procedure/CPT Codes
• Provider's TAX ID
• Provider's NPI
• Provider's Billing Address
• Facility Service/Physical Address
• Date of Service
• Charged Amount(s)

When submitting a medical bill for processing, the member is responsible for obtaining all information needed for processing per the prompts in the online submission portal.

Prepayment. When prepayment is requested, REDEEM HealthShare 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, we 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 choice, 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 actually paid by the member.

Right to Reject Charges. REDEEM HealthShare has the discretion to declare amounts ineligible for sharing it finds unreasonable, excessive, or duplicate charges.

B. Approved Sharing of Bills

To be eligible for sharing, bills for professional services—including assessing, diagnosing, treating, reporting, or giving advice in a medical capacity—must be submitted by the medical provider via the EDI on the REDEEM Member Card, on a Superbill, on a CMS 1500 form, or UB and IB form, or uploaded by the member through the online bill submission portal in the Member Center. The services or items in the bills must be ordered or provided 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 Assistant (P.A.)
• Doctor of Podiatric Medicine (D.P.M.)
• Dentist (D.D.S. or D.M.D.)
• Midwife (if certified)
• Ophthalmologist
• Chiropractor

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

• Hospital
• Surgery center
• Clinic
• Doctor's office
• Diagnostic facility
• Residential setting (for home births or hospice care only)

C. Sharing Limits

Certain conditions may be eligible for sharing, subject to a membership AUA and Co-Share amounts and other conditions that may apply. See each category below for details.

First 90 Days of Membership. For the first 90 days, only bills resulting from injury, acute illness, or accident are eligible for sharing, up to a maximum of $50,000 per household membership. This waiting period does not apply to Samaritan Ministries Legacy Members.

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. This waiting period does not apply to Samaritan Ministries Legacy Members.

• Arthritis
• Autoimmune conditions
• Bone spurs (bone calcification)
• Cataracts
• Glaucoma
• Lyme disease
• Macular degeneration
• Sleep related restricted airway conditions (e.g., sleep apnea) including CPAP equipment
• Varicose veins

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. This waiting period does not apply to Samaritan Ministries Legacy Members.

• Allergy treatments
• Hormone therapy
• Joint replacement
• Lipedema/Lymphedema/Liposuction
• Prosthetics

D. 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. 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 and every year thereafter, this limit increases to $500,000.

This waiting period does not apply to Samaritan Ministries Legacy Members. Conditions and treatments that were eligible for sharing according to the Pre-Existing Conditions in the Guidelines for Health Care Sharing in Samaritan™ Classic and Basic are eligible to be shared without waiting in REDEEM HealthShare.

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.

Pre-existing Condition Exceptions:

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

E. Medically Necessary

Eligible bills may be submitted to be approved for sharing subject to permitted sharing levels when medically necessary. Medically necessary 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 or maternity 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. To be considered medically necessary in REDEEM Essential, REDEEM Enhanced, or REDEEM SeniorSaver, the service must meet all of the following requirements:

• 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 in the United States by CMS (Medicare).

REDEEM HealthShare 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 bill.

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, CMS, and REDEEM HealthShare's own medical advisors.

Off-label Drugs. Sharing of 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:
  • DRUGDEX;
  • The American Hospital Formulary Service Drug Information;
  • Medicare approved Compendia; or<
  • 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 the drug is medically necessary to treat the specific condition, including life threatening conditions or chronic and seriously debilitating conditions.

F. Limited Sharing

Medical bills for specific conditions might be eligible for limited sharing, depending on a member's AUA, any Co-Share amount, and other applicable conditions. Refer to each category below for detailed information.

1. Maternity and Newborns

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. This 12-month waiting period also restarts after a switch from REDEEM Essential to REDEEM Enhanced or from a higher to a lower AUA.

Maternity Services Eligible for Sharing

• Antepartum care
• Labor and delivery
• Postpartum care
• Well-baby visits for the first three years are shareable if the membership has been part of REDEEM Enhanced for 12 months prior to the delivery date. Well-baby services are not subject to the AUA.

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

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

Approved Providers for Delivery. To be eligible, delivery must be performed by a Medical Doctor (M.D.), Doctor of Osteopathy (D.O.), or Midwife who is properly licensed, certified, and/or registered in the state of delivery.

Ectopic Pregnancies

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.

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.

2. Prescription Medications

Inpatient Prescriptions. Prescriptions administered as part of inpatient treatment are shareable. These are subject to the AUA, applicable Co-Share amounts, and annual maximums.

Outpatient Prescriptions (REDEEM Enhanced only). Prescribed medications are shareable only within the REDEEM Enhanced program. There is an annual cap of $1,000 per household membership, per year. Outpatient prescriptions are not subject to the AUA.

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

3. Mental Health

Costs for involuntary commitment up to $50,000 per year are shareable and subject to AUA and Co-Share.

Outpatient mental health treatment, such as counseling and therapy, is shareable only through FlexShare.

4. Therapies

Therapies delivered are subject to limitations and must be lawfully prescribed by a licensed medical professional. It must be a physical condition being treated—not a psychological, emotional, or spiritual condition. Examples of conditions we don't share for: Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder, Sensory Processing Disorder, Post Traumatic Stress Disorder, and cognitive developmental issues. For each of the three eligible therapy categories, there is a $5,000 cap per category, per household membership per year, for a total of $15,000 per year:

Category A: Physical and Manipulative Therapies ($5,000 cap per household membership per year)

• Acupuncture/Acupressure
• Cardiac
• Chiropractic care
• Disc decompression
• Dry needling
• Hyperbaric treatments
• Massage therapy
• Occupational therapy
• Physical therapy
• Respiratory
• Softwave therapy
• Speech therapy
• Vision

Category B: Hormone Therapies ($5,000 cap per household membership per year)

• Androgen replacement therapy
• Menopause related conditions
• Pregnancy/Maternity support (excluding IVF)

Category C: Injection Therapies ($5,000 cap per household membership per year)

• Platelet Rich Plasma/Stem Cells
• Prolotherapy
• Steroid and corticosteroid

Cosmetic injectables, such as dermal fillers, botulinum toxins, and body contouring are not shareable.

These therapies and treatments are subject to the AUA and Co-Share amounts. They must not be for pre-existing conditions.

5. Joint Replacement

Medical bills related to replacement of orthopedic joints (e.g., knee, hip, or shoulder) will only be eligible for sharing after the initial membership 12-month waiting period and 12 consecutive months of membership in the same program and AUA level.

6. Motor Vehicle Related

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 submitting the bill was operating the vehicle, the vehicle must not have been operated recklessly.

7. Medical Transportation

Bills for medically necessary, emergency ground transportation (i.e., ambulances) or air transportation (e.g., Life Flight) are eligible for sharing. These are subject to the AUA and Co-Share amounts.

8. Telemedicine

No-cost 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. Telemedicine from other providers is subject to AUA and Co-Share as applicable.

9. 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 the REDEEM SeniorSaver program, then Medicare must provide their coverage first before any non- covered portions can be shareable by REDEEM members.

10. Skilled Nursing Facility

Skilled nursing facility expenses are shareable for up to $10,000 per member per year subject to AUAs and Co-Shares for a shareable condition requiring rehabilitation or skilled care following a surgery or injury.

11. Routine & Wellness Visits (REDEEM Enhanced)

Routine and wellness visits are eligible for sharing only if the member is part of the REDEEM Enhanced program. Each member is eligible for one routine visit per year. These routine wellness visits are capped at $300 per person, per year and are not subject to the AUA requirements.

12. Immunizations (REDEEM Enhanced)

Immunizations and the associated office visit are shareable for children who are part of REDEEM Enhanced from birth until 2 years of age. The cost of immunizations may be shared for children who are part of REDEEM Enhanced between the ages of 3 and 6 years of age as part of the child's annual routine visit subject to the $300 annual per person member cap.

Immunization costs are not subject to the AUA and Co-Share amounts.

13. Preventative Screenings (REDEEM Enhanced)

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:

Mammogram. Women are eligible for one mammogram or breast ultrasound per year beginning at age 45. These bills are not shareable within the first six months of membership and are not subject to AUA.

Prostate-Specific Antigen Test (PSA). Men are eligible for one PSA test per year beginning at age 45. These bills are not shareable within the first six months of membership and are not subject to AUA.

Colonoscopy. Adults are eligible for one colonoscopy every five years per person or every two 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. These bills are not subject to the AUA and are not eligible for sharing within the first six months of membership.

Gynecological. Women are eligible for annual gynecological wellness visits, including Pap tests each year. These bills are not subject to the AUA and are not eligible for sharing within the first six months of membership.

14. Direct Primary Care

Both "Direct Primary Care" and "Concierge Medicine" are methods by which consumers pay a regular fee, usually monthly, to secure more favorable access to a primary care physician. That monthly fee for a member's household is shareable, up to $100 for any month in which, in regards to that need, the physician is consulted, makes a referral, or charges for services.

15. Medical Care Outside of the United States

Bills from medical treatments occurring outside of the United States can be shared. They must be written or translated into English and the price must be converted to U.S. dollars. They must include all the bill itemization requirements in Section III.A.

G. Not Eligible for Sharing

Treatment that is in violation of the Statement of Faith and Lifestyle Requirements (listed in Foundational Principles) including illness or injury arising from grossly negligent acts, use of illegal drugs, abuse of alcohol, or any illegal activity, whether an arrest is made, charges are filed, or a conviction results, is not eligible for sharing. Additionally, the following expenses are not eligible for sharing, unless noted:

1. Cosmetic surgeries, injections, or procedures, 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, except as specified in Section III.G.
6. Bills related to an event while on active military duty
7. Bills that are required to be covered by worker's compensation insurance
8. Any injury or illness arising from any illegal activity
9. Any charges where a third-party is responsible
10. Charges not submitted within twelve (12) months from the Date of Service (DoS)
11. Charges for the release of medical records
12. Charges for anything relating to transsexualism, gender dysphoria, sexual reassignment, or change, including medications
13. 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
14. Drug/alcohol abuse treatment
15. Procedures or surgery that is not medically necessary
16. Prophylactic (treatment intended to prevent disease) and preventive surgery without personal history of diagnosis and a doctor's recommendation.
17. Experimental treatment
18. Birth control
19. Abortion
20. Complications related to ineligible procedures, conditions, and diagnoses except pre-existing maternity. If complications arise from a medical procedure that is not shareable, expenses for treating the complications are shareable unless the procedure that was the cause was not shareable due to moral reasons (e.g., abortion) or the complication itself is not shareable (e.g., a routine dental problem arising from the treatment of a routine dental problem).
21. Transportation to appointments
22. Psychotropic medication*
23. Nutrition services*
24. Medical supplies*
25. Gym memberships*
26. Non-medical expenses*
27. Additional wellness visits beyond the one allowed per membership year in REDEEM Enhanced*

Items with an asterisk (*) may be shared under FlexShare.

H. REDEEM SeniorSaver Sharing Limitations

REDEEM SeniorSaver is a sharing program for those aged 65 and over designed to be secondary to Medicare Part A, Part B, and if applicable Medicare Advantage plans. There are some specific exclusions and limits:

1. 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.
2. Prescriptions may be shared only for REDEEM SeniorSaver members with Medicare Part D after Medicare's coverage has been applied and the $500 AUA has been reached.
3. The exceptions to the above would be any bill related to services declared as not eligible for sharing in Section III.G.
4. Blood transfusions: in some scenarios requiring blood transfusion, blood products must be purchased by the provider for the member. Those costs are shareable.
5. Inpatient acute care hospitalization:
   1. Days 1-60: Medicare covers these costs
   2. Days 61-150: Medicare covers the significant portion of costs, the balance is shareable
   3. Days 151-beyond: Not shared