Sharing Guidelines

3. Sharing of Expenses

3.1. REDEEM Essential Sharing of Expenses

As a REDEEM Essential member, you share eligible Needs but do not share preventative screenings, wellness visits, immunizations, or outpatient prescription costs. Eligible Needs under REDEEM Essential are shareable up to a $1 million per household membership cap per year and is subject to a Co-Share.

3.2. REDEEM Enhanced Sharing of Expenses

As a REDEEM Enhanced member, you share eligible Needs as well as certain preventative screenings, wellness visits, immunizations, and prescription costs subject to the Unshareable Amount as documented herein. Eligible Needs under REDEEM Enhanced are shareable up to a $2 million per household membership cap per year and is not subject to a Co-Share.

Additional Eligible Needs with REDEEM Enhanced:

3.2.1. Routine and Wellness Visits

• Each member of your household is eligible for annual routine wellness services up to $300 per member, per year.
• Eligible expenses include any wellness service provided during the wellness visit. For example, the wellness office visit, school physical, labs, immunizations, and wellness related exams.
• The cost of eligible wellness services up to the $300 cap is not subject to the Unshareable Amount. During a wellness visit, however, unrelated eligible medical treatment, such as treatment for an acute illness, is subject to the Unshareable Amount.
• Waiting periods from section 3.7.1 First 90 days of membership apply. However, this waiting period does not apply to Samaritan Ministries Legacy Members.

3.2.2. Gynecology

• Women are also eligible for annual gynecological wellness visits up to $300 per member per year, including Pap tests.
• The cost of eligible gynecological wellness services up to the $300 cap is not subject to the Unshareable Amount.
• Waiting periods from section 3.7.1 First 90 days of membership apply. However, this waiting period does not apply to Samaritan Ministries Legacy Members.

3.2.3. Maternity Well Baby Visits

Well-baby visits are eligible for sharing for three years following an eligible Maternity Need. See 3.10.1 Maternity and Newborns for more information about Maternity eligibility. Well-baby services are not subject to the Unshareable Amount.

3.2.4. Immunizations (vaccination)

• Immunizations and the associated office visit are eligible for sharing for children from birth until 2 years of age. See 3.2.1 Routine and Wellness Visits for immunization eligibility after the age of two.
• The cost of eligible immunization is not subject to the Unshareable Amount.
• Waiting periods from section 3.7.1 First 90 days of membership apply. However, this waiting period does not apply to Samaritan Ministries Legacy Members.

3.2.5. Preventative Screenings

The following preventative screenings are eligible for sharing after the first six months from your Member Start Date in REDEEM HealthShare and are not subject to the Unshareable Amount.

Mammogram

• Women are eligible for an annual mammogram or a breast ultrasound beginning at age 45.

Prostate-Specific Antigen Test (PSA)

• Men are eligible for one PSA test per year beginning at age 45.

Colonoscopy

• Each adult in the household is eligible for one colonoscopy every five years or every two years if you are high-risk (as determined by your physician), beginning at age 45.
• Cologuard (or equivalent testing) is an acceptable substitution for a scheduled colonoscopy if desired.
• Required treatment during the procedure such as polypectomies and pathology are eligible for sharing when part of the original preventative screening.
• You might need to have your bill re-processed if your provider bills the additional treatment separately.
• If your test shows a medical issue, then follow-up procedures, testing, or treatment will be subject to and apply toward your Unshareable Amount. If you have already met your Unshareable Amount, then your bill is eligible for sharing through the usual process.

3.2.6. Outpatient Prescriptions

• There is an annual cap of $1,000 per household membership, per year.
• The cost of outpatient prescriptions are not subject to the Unshareable Amount.
• Waiting periods from section 3.7.1 First 90 days of membership apply. However, this waiting period does not apply to Samaritan Ministries Legacy Members.

3.3. REDEEM SeniorSaver Sharing of Expenses

REDEEM SeniorSaver is a program for you if you are 65 years of age or older.

• You are not required to join REDEEM SeniorSaver when you turn 65. Participation in REDEEM Essential or REDEEM Enhanced is available to you for as long as you like.
• Under REDEEM SeniorSaver only services covered by Medicare Part A, Part B, and, if applicable, Medicare Advantage plans are eligible for sharing. This applies even if a Need would otherwise be eligible for sharing under REDEEM Essential or REDEEM Enhanced.

REDEEM SeniorSaver members use the same guidelines as individuals and households with the following exceptions:

3.3.1. Medicare must first apply its coverage, and you must meet your AUA before you share items covered by Medicare Parts A and B.

3.3.2. (Prescriptions) Medicare must first apply its coverage, and you must have Medicare Part D, and you must have met your AUA.

3.3.3. If you require a blood transfusion, a provider must purchase blood products for you.

3.3.4. Inpatient Acute Care Hospitalization for you:

• Days 1-60: Medicare covers these costs.
• Days 61-150: Medicare covers a significant portion of costs; the balance is shareable.
• Days 151-beyond: Not eligible for sharing.

3.3.5. Participation is available for individual memberships only. Couples participating in REDEEM SeniorSaver requires two individual memberships. If you want to have a couple or family membership, you will need to participate in REDEEM Essential or REDEEM Enhanced.

3.3.6. The waiting periods and pre-existing conditions limitations in section 3.7 Sharing Limits and section 3.8 Pre-existing Conditions do not apply.

3.3.7. Care outside of the United States is not eligible for sharing in REDEEM SeniorSaver.

3.4. REDEEM Groups Sharing of Expenses

REDEEM Groups Overview

REDEEM HealthShare Groups is an option if you are affiliated with a group, such as employers, associations, or other multi-household groups, to fund and manage REDEEM memberships.

All REDEEM HealthShare programs are available to groups, including REDEEM Essential, REDEEM Enhanced, and REDEEM SeniorSaver. The FlexShare add-on is also available to REDEEM HealthShare Groups.

• Participation in a group does not change your individual membership responsibilities or requirements.
• Each membership within the group must individually meet the membership requirements and apply.
• You can voluntarily end your Group affiliation at any time.
• A Sponsor Administrator or Group Administrator can also end your Group affiliation at any time.
• Ending a Group affiliation does not inactivate your REDEEM HealthShare membership.
• Upon the Effective Date of the change, you are individually responsible for funding your Share Wallet in accordance with the Guidelines.

REDEEM HealthShare membership does not fulfill the Affordable Care Act employer mandate. Employer-funded groups should consult local legal counsel regarding federal and state compliance obligations.

If you participate in REDEEM HealthShare through a Group, you authorize REDEEM HealthShare to share information regarding your membership with the Sponsor Administrator or Group Administrator for purposes of administration, funding, and resolution of membership issues.

REDEEM® Groups use the same guidelines as individuals and households with the following exceptions: Maternity expenses in section 3.10.1 Maternity and Newborns are eligible for individual memberships if the member is married.

3.5. Expenses Eligible for Sharing

To be eligible for sharing, a bill must be:

3.5.1. Free from unreasonable, excessive, or duplicated amounts, as determined in the discretion of REDEEM HealthShare.

3.5.2. Not listed as not eligible, which means the bill must not be listed in section 3.11 Not Eligible for Sharing.

3.5.3. Within submission time limit, which means a provider or you must submit the bill to REDEEM HealthShare within 12 months of the date of service.

3.5.4. The result of condition, injury, or illness

• The bill must be for a condition, injury, or illness and have a date of service after your start date. Note: Bills for pre-existing eligible conditions are also eligible for sharing under certain circumstances. See section 3.8 Pre-existing Conditions for details. In every case, bills must always have a date of service after the Member Start Date to be eligible for sharing.
• The bill must be for treatment of physical conditions, not primarily psychological, emotional, or spiritual conditions. Examples of conditions that are not eligible for sharing: Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder, Sensory Process Disorder, Post Traumatic Stress Disorder, and cognitive developmental issues.

3.5.5. For services incurred or qualifying estimates or prepayments

• In most instances the bill must be for actual services incurred.
• For maternity, you may submit bill estimates for consideration.
• For other cases where paying upfront results in significant savings, contact Member Care for more details.
• When a provider requests prepayment, REDEEM HealthShare will make every effort to negotiate with the provider or facility to ensure that we obtain a rate that is consistent with our Permitted Sharing Level. If the provider or facility is unable to provide a rate that meets our Permitted Sharing Level, we will make every effort to find a provider or facility whose fees are closer to our Permitted Sharing Level. You may choose to see the provider of your choice, but if the rate is more than our Permitted Sharing Level, then REDEEM HealthShare will limit the prepayment and sharing to 200% of the CMS rate, and you will pay the remaining balance directly to the provider. Based on what you paid, REDEEM HealthShare will publish the eligible bills paid in full.

3.6. Approved Sharing of Bills

To be eligible for sharing, providers must submit their billing via 1) the Electronic Data Interchange (EDI) on the REDEEM Member Card, 2) a Center for Medicare and Medicaid Services card (CMS) 1500, or 3) a Uniform Billing (UB). Bills submitted by providers must follow standard healthcare industry submission and coding guidelines to meet sharing consideration.

Many medical providers are willing to submit their bills electronically via the Member Card EDI number. However, if you manually submit a bill for processing, you must submit the bill using the online submission portal in the Member Center. Ask your provider for a superbill, which is a common and comprehensive healthcare industry billing documentation format. The healthcare industry uses multiple terms interchangeably to describe a medical bill such as, superbill, itemized statement, patient ledger, or account history (not a comprehensive list).

Member submitted bills and documents must include the following itemized details:

• Name of patient
• Diagnosis and International Classification of Diseases (ICD-10) codes
• Procedure and Current Procedural Terminology (CPT) codes
• Provider’s TAX ID
• Provider’s National Provider Identifier (NPI)
• Provider’s billing address
• Facility service and physical address
• Date of service
• Charged amounts

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

The services or items in the bills must be eligible for sharing and within the scope of licensing and ordered or provided 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
• Optometrist
• Optician
• Chiropractor

These tests and treatments must occur at a CMS designated site of care or one of the following:

• Hospital
• Ambulatory center
• Clinic
• Doctor’s office
• Diagnostic facility (lab or imaging)
• Independent Facilities
• Residential setting (for home births, hospice care, and pre-approved home health)
• Skilled Nursing and Rehabilitation Facility
• Telehealth

3.7. Sharing Limits

This section does not apply to REDEEM SeniorSaver members because the required waiting periods do not apply to REDEEM SeniorSaver. See section 3.3 REDEEM SeniorSaver Sharing of Expenses.

Other restrictions apply to the sharing of eligible needs, in addition to your Unshareable Amount. See each category below for details on such restrictions.

3.7.1. First 90 days of membership

For the first 90 days from the Member Start Date, only Needs 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.

3.7.2. First year of membership

The following conditions and treatments are not eligible for sharing in the first 12 months from the Member Start Date. This limitation does not apply to treatment required as the result of an accident during membership. For Samaritan Ministries Legacy Members who join REDEEM HealthShare without membership interruption, this waiting period begins based on your start date in the Legacy program.

• Arthritis
• Autoimmune conditions
• Allergy treatments
• Back Surgery
• Bone spurs (bone calcification)
• Cataracts
• Glaucoma
• Hormone therapy
• Joint replacement
• Lipedema, Lymphedema, Liposuction
• Lyme disease
• Macular degeneration
• Maternity and newborns see section 3.10.1 Maternity and Newborns.
• Prosthetics
• Sleep related restricted airway conditions, for example, sleep apnea and including CPAP equipment
• Varicose veins

3.8. Pre-existing Conditions

This section does not apply to REDEEM SeniorSaver members because each program includes its own specific requirements regarding pre-existing conditions. REDEEM SeniorSaver members see section 3.3 REDEEM SeniorSaver Sharing of Expenses.

A pre-existing medical condition refers to conditions in which known signs, symptoms, testing, treatment (routine or maintenance), diagnosis, or use of medication (routine or maintenance) occurred within 36 months prior to your Member Start Date. Any pre-existing condition known to exist at your Member Start Date has a three-year waiting period from your Member Start Date for bill sharing. After this waiting period, sharing towards pre-existing conditions is up to $125,000 per member, per year. In the sixth year of your membership, and every year thereafter, this limit increases to $500,000. Note: REDEEM HealthShare does not count testing, for the purpose of monitoring a prior resolved condition, as pre-existing, so long as the tests indicate the continued resolution of the issue.

For Samaritan Ministries Legacy Members who join REDEEM HealthShare without membership interruption, this waiting period begins based on your start date in the Legacy program. 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 for sharing.

3.8.1. Adoption

For adoption, a pre-existing condition refers to any physical condition the child has that the adopting parents either knew of or had reason to know of prior to their legal responsibility for the child’s expenses, or prior to the child’s effective date within your membership. See section 5.9 Other Responsible Parties for expectations related to exhausting other health benefits before submitting a request for sharing.

3.8.2. Pre-existing condition exceptions

3.9. Medically Necessary

You may submit eligible bills for sharing approval when they are medically necessary and meet the permitted sharing levels.

3.9.1. Definition of Medically Necessary

Medically necessary refers to health care services that are clinically appropriate in terms of type, frequency, extent, site, and duration for the diagnosis or treatment of sickness, or injury.

3.9.2. Qualified Medical Professionals

A qualified, licensed medical professional must use prudent clinical judgment and must have one of the designations listed in section 3.6 Approved Sharing of Bills to order services or treatments for the purposes of evaluation, diagnosis, or treatment of sickness or injury.

3.9.3. Criteria for Medically Necessary Services

The setting and level of service must 1) be able to provide care that is unavailable using a less intensive medical setting and 2) match your medical symptoms and conditions. Services must not cost more than other treatment options, including doing nothing, that work as well without harming your health. The medically necessary service must meet all the following requirements:

• Its purpose must be to restore health.
• It must be eligible for reimbursement in the United States by CMS (Medicare) or listed in section 3.10 Limited Sharing.
• It must be eligible for sharing per the program Guidelines.
• It must not be maintenance therapy or maintenance treatment.
• It must not be primarily custodial in nature.

REDEEM HealthShare considers CMS (Medicare) guidelines in effect on the date of treatment, along with findings from the AMA, CMS, and its medical advisors, when determining medical necessity and bill eligibility.

Even though a provider delivered, prescribed, or approved service does not mean that it is medically necessary.

3.9.4. Off-label Drugs

REDEEM HealthShare considers sharing of off-label drug use medically necessary when the off-label drug meets the following conditions:

• FDA approval.
• One of the following standard reference sources supports the prescribed drug’s use:
  • DRUGDEX.
  • The American Hospital Formulary Service Drug Information.
  • Medicare-approved compendia.

Scientific evidence must come from well-designed clinical trials published in peer-reviewed medical journals. These studies must demonstrate that the drug is safe and effective for the specific condition. The drug is medically necessary to treat the specific condition, including life-threatening conditions or chronic and seriously debilitating conditions.

3.10. Limited Sharing

Needs for specific conditions might be eligible for limited sharing, depending on your Unshareable Amount, and other applicable conditions. Refer to each category below for detailed information.

3.10.1. Maternity and Newborns

3.10.2. Prescription Medications

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

Outpatient Prescriptions. REDEEM Enhanced members should reference section 3.2.6 Outpatient Prescriptions and REDEEM SeniorSaver Members should reference section 3.3 REDEEM SeniorSaver Sharing of Expenses for specific outpatient prescription eligibility.

Exceptions for Outpatient Prescriptions
REDEEM HealthShare may make exceptions for medications for cancer and transplant recipients. Requirements for exception consideration include application to a Patient Assistance Program and other available programs for medication cost when available.

3.10.3. Mental Health

Costs for involuntary commitment up to $50,000 per year are shareable and subject to the Unshareable Amount.

3.10.4. Therapies

Outpatient therapies delivered are subject to the Unshareable Amount and must be eligible for sharing per the program Guidelines. For each of the three eligible therapy categories, there is a $5,000 cap per category, per household membership per year:

Category A: Hormone Therapies ($5,000 cap per household membership per year), such as:

• Androgen replacement therapy
• Menopause related conditions
• Pregnancy and maternity support (excluding IVF)

Category B: Injection Therapies ($5,000 cap per household membership per year), such as:

• Platelet Rich Plasma or Stem Cells therapy
• Prolotherapy
• Steroid and corticosteroid injections
• Allergy shots and serum
• Nerve blocker
• Eye Injections for Macular Degeneration

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

• Acupuncture or Acupressure
• Cardiac therapy
• Chiropractic care
• Disc decompression
• Dry needling
• Hyperbaric treatments
• Massage therapy
• Occupational therapy
• Physical therapy
• Respiratory therapy
• Softwave or Shockwave therapy
• Speech therapy
• Sublingual Immunotherapy
• Vision therapy
• Home Care includes skilled care by a registered ARNP, LPN, or RN for at home services for an eligible Need ordered by a qualified provider for members who are homebound for that Need. REDEEM HealthShare limits visit sharing to a maximum block of 4 hours.

REDEEM HealthShare may make exceptions in the case of therapies for cancer treatment and transplant recipients. Requirements for exception consideration include application to a Patient Assistance Program and other available programs for medication cost when available.

3.10.5. Sharing Limits, Waiting Periods, and Pre-existing Conditions (for joint replacement and other conditions)

See section 3.7 Sharing Limits for waiting periods during the first 12 months of membership and section 3.8 Pre-existing Condition limitations.

The waiting period and pre-existing conditions requirements referenced in this subsection do not apply to REDEEM SeniorSaver members. REDEEM SeniorSaver members, see section 3.3 REDEEM SeniorSaver Sharing of Expenses.

3.10.6. Motor Vehicle Related

Medical bills incurred for injuries resulting from motorized vehicles only meet sharing eligibility 1) after any insurance entity or other liable third party has paid their portion 2) provided you meet all other Guideline requirements, and 3) if the operator did not operate the vehicle recklessly. To determine eligibility, report the motor vehicle related injuries to Member Care.

3.10.7. Medical Transportation

Bills for medically necessary, emergency ground or air transportation are eligible for sharing. Both types of transportation are subject to the Unshareable Amount.

3.10.8. Telemedicine

The approved REDEEM HealthShare telehealth provider is free and available through the Member Center and is not subject to your Unshareable Amount. Telemedicine from other providers is subject to your Unshareable Amount.

3.10.9. Hospice Care

Hospice care services are subject to the Annual Sharing Cap. These services are eligible for sharing for 90 days upon prescription by a physician or certification that the person is terminally ill. For continued sharing eligibility, you must submit a renewed prescription or certification. Note: If you are in the REDEEM SeniorSaver program, then Medicare must provide your coverage first before the REDEEM community considers sharing eligible non-covered portions.

3.10.10. Skilled Nursing Facility

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

3.10.11. Direct Primary Care

Both “Direct Primary Care” and “Concierge Medicine” are methods by which you pay a regular fee, usually monthly, to secure more favorable access to a primary care physician. The monthly fee for your household (should you use one of these methods) is shareable, up to $100 for any month you, or someone in your household consults the physician, or the physician makes a referral or charges for services.

3.10.12. Medical Care Outside of the United States

You may share bills from medical treatments occurring outside of the United States. You must include all the bill itemization requirements listed in section 3.6 Approved Sharing of Bills, and translate the information into English and convert the price into U.S. dollars.

The international care requirements described in this subsection do not apply to REDEEM SeniorSaver Members. REDEEM SeniorSaver members, see section 3.3 REDEEM SeniorSaver Sharing of Expenses.

3.10.13. Immunizations (vaccinations)

REDEEM Enhanced Members see section 3.2.4 Immunizations (vaccinations) for limited sharing for REDEEM Enhanced members.

REDEEM Essential Members see section 3.1 REDEEM Essential Sharing of Expenses.

3.11. Not Eligible for Sharing

The following expenses are not eligible for sharing unless noted:

3.11.1. Member Conduct, Responsibility, or Third-Party Liability

• Bills related to an event while on active military duty.
• Bills that worker’s compensation insurance should cover.
• Any charges where a third-party is responsible.
• Treatment arising from actions in violation of Member Requirements, 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. For more information, see section 1. Foundational Overview.

• Complications related to procedures, conditions, and diagnoses that are not eligible for sharing, except pre-existing maternity. Note: If complications arise from a medical procedure that is not eligible for sharing, expenses to treat the complications are eligible for sharing unless:

  • The procedure that caused the complication was not eligible for sharing due to moral reasons, for example, an abortion.
  • The complication itself is not shareable, for example, a routine dental problem arising from the treatment of a routine dental problem.

3.11.2. Cosmetic, Elective, or Non-Medically Necessary Procedures

• Procedures or surgery that are not medically necessary.
• Weight management treatment or procedures.
• Prophylactic (treatment intended to prevent disease) and preventive surgery without personal history of diagnosis and a doctor’s recommendation.
• Medical marijuana.
• Experimental treatment.
• Cosmetic surgeries, injections, or procedures, except for:
  • Breast reconstruction after cancer for the affected breast and the non-affected breast only if the breast cancer is eligible for sharing and only if recommended for symmetry purposes. Revisions of initial breast reconstructions are not eligible for sharing except in cases of infection, necrosis, or treatment of lymphoma.
  • Medically necessary breast reduction.
  • Reconstructive surgery from any injury.
  • Cleft palate.
  • Birth defect, such as missing all or part of an ear.

3.11.3. Reproductive, Fertility, or Sexual Health

• Medication or treatment for sexual health or dysfunction.
• Fertility or Infertility treatment.
• In-vitro fertilization.
• Charges for anything relating to transsexualism, gender dysphoria, sexual reassignment, or change, including medications.
• Birth control for the purpose of contraception.
• Abortion.
• Surrogacy.

3.11.4. Genetic, Congenital, or Hereditary Conditions

• Non-required genetic testing for treatment of an existing condition.
• Treatment related to genetic defects, hereditary diseases, or congenital conditions that were known or producing symptoms before membership.

3.11.5. Mental Health, Behavioral, and Neurodevelopmental Care

• Inpatient psychological treatment except as specified in section 3.10 Limited Sharing, 3.11.5 Mental Health, Behavioral, and Neurodevelopmental Care.
• Outpatient mental health treatment, such as counseling, therapy, special education charges, and care for learning deficiencies, or behavioral problems, except as specified in section 3.10.3 Mental Health.
• Drug and alcohol abuse treatment.
• Psychological, emotional, or spiritual conditions.
• Neurodevelopmental conditions including but not limited to; attention deficit disorder, attention deficit hyperactivity disorder, sensory process disorder, post-traumatic stress disorder, and cognitive developmental issues.
• Psychotropic medication. See section 3.10.4 Therapies, Category C Other Therapies for exceptions.

3.11.6. Administrative, Billing, or Documentation Issues

• Bill irregularities:
  • Charges not submitted within twelve (12) months from the date of service. REDEEM HealthShare must receive any additional information requested from the member or provider no later than 12 months from the date of service or 90 days after the date requested, whichever is later.
  • Excessive or unnecessary provider charges which include afterhours, holiday, and weekend fees. Note: See sections 3.6 Approved Sharing of Bills and 7.3. Permitted Sharing Levels for more information.
• Charges for the release of medical records.
• Lost discounts due to late payments of Unshareable amounts.

3.11.7. Non-Medical, Educational, or Custodial Services

• Care for symptoms not related to a specifically diagnosable disease or injury, such as ongoing fatigue and malaise.
• Consultations including but not limited to dietary, diabetic, lactation, and genetic counseling.
• Custodial or long-term care.
• Educational services and materials including but not limited to: Lamaze, breast feeding, and early childhood intervention.
• Gym memberships.
• Non-medical expenses.
• Nutrition services.
• Premiums for insurance products.

3.11.8. Durable Medical Equipment, Supplies, and Related Services

• Durable Medical Equipment including but not limited to mobility equipment such as motorized wheelchairs or scooters, exercise equipment, and home modifications. Does not include CPAP to treat a specific disease when ordered by a qualifying provider.
• Hearing aids.
• Non-prescription (over the counter) drugs, medical supplies, and equipment
• Orthotics.

3.11.9. Dental, Vision, Sleep, and Condition-Specific Services

• Dental or vision services not related to a shareable medical injury or illness.
• Sleep studies not related to a specific disease or disorder.

3.11.10. Transportation and Travel

• 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.
• Transportation to appointments.

3.11.11. Ineligible Providers, Conflicts of Interest, and Stewardship Safeguards

REDEEM HealthShare may determine, in its discretion, that medical bills from certain providers or facilities are ineligible for sharing. These determinations are made as part of REDEEM HealthShare’s responsibility to steward member-to-member sharing, protect the integrity of the sharing process, and provide consistent administration of the Guidelines.

REDEEM HealthShare may determine, in its discretion, that a provider or facility is ineligible for sharing for reasons related to program administration, process integrity, or stewardship considerations, including situations involving conflicts of interest.

When REDEEM HealthShare determines that a provider or facility is ineligible for sharing, it will take reasonable steps to provide notice so you can make informed decisions regarding your medical care and sharing submissions. REDEEM HealthShare provides notification through one or more of the following methods:

• Information from Member Care when you ask about provider eligibility.
• Notification through the Member Center or other member-accessible systems.
• Notification during bill submission, care navigation, or sharing adjudication.

You are responsible for disclosing any conflicts of interest, including self-treatment, treatment of immediate family members, or financial relationships between you and a provider or facility. The absence of prior notice does not make bills arising from a conflict of interest eligible for sharing.