Sharing Guidelines

III. Sharing of Expenses

A. Expenses Eligible for Sharing

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

To be eligible for sharing, a bill must 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 member 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 member 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.F) or in FlexShare.

The bill must be for a physical condition being treated—not a psychological, emotional, or spiritual condition. Examples of ineligible conditions: Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder, Sensory Process Disorder, Post Traumatic Stress Disorder, and cognitive developmental issues.

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. Please contact Member Care for more details.

Prepayment. 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. The member can choose to see the provider of their 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 the member will directly pay the remaining balance.

The member can share any bills paid in full based off what the member paid.

Be Not Listed as Not Eligible:

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

Within Submission Timeframe:

A provider or member must submit the bill to REDEEM HealthShare within 12 months of the date of service.

B. Approved Sharing of Bills

To be eligible for sharing, a provider 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) and Integrated Billing (IB) form. Bills submitted by the provider must follow standard healthcare industry submission and coding guidelines to meet sharing consideration.

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, the member must submit the bill using the online submission portal in the Member Center. Members should ask their provider for a Superbill, which is a common and comprehensive healthcare industry billing documentation format.

Member submitted bills 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, the member is 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 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 one of the following:

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

C. Sharing Limits

Certain conditions may be eligible for sharing, subject to 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. For Samaritan Ministries Legacy Members who join REDEEM without membership interruption, this waiting period begins at the member's start date in the legacy program. When selected, FlexShare always has an initial 6 month waiting period. Bills for these conditions are eligible for FlexShare after the initial 6 month waiting period:

• Arthritis
• Autoimmune conditions
• Bone spurs (bone calcification)
• Cataracts
• Glaucoma
• Lyme disease
• Macular degeneration
• Sleep related restricted airway conditions, for example, sleep apnea and 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. For Samaritan Ministries Legacy Members who join REDEEM without membership interruption, this waiting period begins at the member's start date in the legacy program. Bills for these conditions are eligible in FlexShare, if that option is selected, after the initial 6-month waiting period.

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

D. Pre-existing Conditions

For Samaritan Ministries Legacy Members who join REDEEM without membership interruption, this waiting period begins at the member's 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 to be shared without waiting in REDEEM HealthShare.

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 his or her parents’ membership.

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.C 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: Members can submit bills for pre-existing high blood pressure for sharing provided members have not received hospital treatment for high blood pressure in the last five years, and medication or diet control the condition.
• Elevated Cholesterol: REDEEM HealthShare does not consider elevated cholesterol a pre-existing condition, even when a provider prescribes a statin. However, REDEEM HealthShare does consider elevated cholesterol a pre-existing condition when a provider prescribes a statin to treat a diagnosis like arteriosclerosis.

E. Medically Necessary

When medically necessary, members may submit eligible bills—subject to permitted sharing levels—for sharing approval. 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, injury, or maternity and ordered by a physician exercising prudent clinical judgment for the purposes of evaluation, diagnosis, or treatment of sickness, injury, or maternity.

The medically necessary setting and level of service must 1) be able to provide care using a less intensive medical setting and 2) match the member’s medical symptoms and conditions. For medically necessary consideration, such services 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. In REDEEM Essential, REDEEM Enhanced, or REDEEM SeniorSaver, 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 III.F.
• 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 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.

Even though a provider furnished, prescribed, or approved a service 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 medical advisors for REDEEM HealthShare.

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.

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.

For Samaritan Ministries Legacy Members who join REDEEM without membership interruption, this waiting period begins at the member’s start date in the legacy program. REDEEM HealthShare makes an exception when one of the members has been active for 12 months and adds their future spouse or spouse within 30 days before or after the wedding day. If the member applies to add their spouse and the ministry approves then sharing in eligible needs including a pregnancy occurring on or after the marriage date will start on the marriage date.

Maternity Services Eligible for Sharing

• Antepartum care
• Labor and delivery
• Postpartum care
• Well-baby visits for the first three years when 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. Primary member must add the baby 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, then—after the membership meets their AUA—any bills are eligible for sharing per the program Guidelines.

Approved Providers for Delivery. For bills to meet eligibility, a Medical Doctor (M.D.), Doctor of Osteopathy (D.O.), or a Midwife who is properly licensed, certified, 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.

Exceptions may be made in the case of medications for cancer and transplant recipients. Requirements for exception consideration include application to a Patient Assistance Program (PAP) and other available programs for medication cost when available.

REDEEM SeniorSaver members who want to share prescription bills must also have Medicare Part D.

FlexShare Prescriptions. When members are part of FlexShare, they can submit prescription costs not shareable under the above categories to FlexShare. Expenses must be eligible for sharing per the program Guidelines.

3. Mental Health

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

Voluntary inpatient and outpatient mental health treatment, such as counseling, therapy, special education charges, and care for learning deficiencies or behavioral problems are only shareable 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.Therapies delivered are subject to AUA and Co-Share 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, for a total of $15,000 per year:

Category A: Physical and Manipulative 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
• 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. A visit is limited to a maximum block of 4 hours.

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

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

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

• Platelet Rich Plasma or Stem Cells therapy
• Prolotherapy
• Steroid and Corticosteroid injections

Exceptions may be made in the case of therapies for cancer treatment and transplant recipients. Requirements for exception consideration include application to a Patient Assistance Program (PAP) and other available programs for medication cost when available.

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

See Sharing Limits section III.C. for waiting periods during the first 12 months of membership and section III.D. for pre-existing condition limitations.

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 and, 2) provided all other Guideline requirements are met. If the member submitting the bill was operating the vehicle, then the member must not have operated the vehicle recklessly. To determine eligibility, report the motor vehicle related injuries to Member Care.

7. Medical Transportation

Bills for medically necessary, emergency ground or air transportation are eligible for sharing. Both types of transportation are subject to the AUA and Co-Share amounts.

8. Telemedicine

No-cost urgent care telemedicine conducted using ourThe approved REDEEM HealthShare telehealth provider is freelyfree and available through the Member Center and is not subject to theyour AUA andor any applicable Co-Share. Telemedicine from other providers is subject to your AUA and any applicable Co-Share as applicable.

9. Hospice Care

Hospice care services are subject to the per-year dollar maximum. 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, members must submit a renewed prescription or certification. 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 and are 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 when the member is part of the REDEEM Enhanced program. Each member is eligible for one routine visit and labs per year. Members can substitute a traditional wellness visit with a school physical. The limit for routine wellness visits and labs is $300 per person, per year. The cost of a routine visit or a school physical is not subject to the AUA requirements.

12. Immunizations (REDEEM Enhanced)

For members in REDEEM Enhanced, immunizations and the associated office visit are shareable for children from birth until 2 years of age. The cost of immunizations is shareable for children between the ages of 3 and 6 years of age when the immunizations are part of the child’s annual routine visit and subject to the $300 annual per person member limit.

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

13. Preventative Screenings (REDEEM Enhanced)

These preventative screenings are eligible for sharing when the member is part of the REDEEM Enhanced program and are subject to the following conditions:

Mammogram. Women are eligible for an annual mammogram or a breast ultrasound beginning at age 45. These bills are not eligible for sharing within the first six months of the Member Start Date and are not subject to AUA.

Gynecology. Women are eligible for annual gynecological wellness visits, including Pap tests. The limit is $300 per person, per year. These bills are not eligible for sharing with the first six months of the Member Start Date 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 the Member Start Date 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. Members may substitute Cologuard (or equivalent testing) 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 the Member Start Date. Required treatment during the procedure such as polypectomies and pathology are eligible for sharing when part of the original preventative screening. You may need to have your bill re-processed if your provider bills the additional treatment separately. If your test shows a medical issue, follow-up procedures, testing, or treatment will be subject to and apply toward your AUA, and Co-Share.

If you have already met your AUA, then your bill is eligible for sharing through the usual process.

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. The monthly fee for a member’s household is shareable, up to $100 for any month members of a household consult the physician, or the physician makes a referral or charges for services.

15. Medical Care Outside of the United States

Members can share bills from medical treatments occurring outside of the United States. You must include all the bill itemization requirements in Section III.B and that you have translated the information into English and convert the price into U.S. dollars.

G. Not Eligible for Sharing

The following expenses are not eligible for sharing unless noted:

1. Treatment that is in violation of the 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 the Foundational Overview section.
2. Cosmetic surgeries, injections, or procedures, with exceptions:
   1. 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 ineligible for sharing except in cases of infection, necrosis, or treatment of lymphoma.
   2. Medically necessary breast reduction.
   3. Reconstructive surgery from any injury.
   4. Cleft palate.
   5. Birth defect – like missing all or part of an ear.
3. Medication or treatment for sexual health or dysfunction.
4. Fertility or Infertility treatment.*
5. In-vitro fertilization
6. Non-required genetic testing for treatment of an existing condition.*
7. Treatment related to genetic defects, hereditary diseases, or congenital conditions which was known or producing symptoms before membership.
8. Inpatient psychological treatment*, except as specified in section III.F. Limited Sharing | 3. Mental Health
9. Outpatient mental health treatment, such as counseling, therapy, special education charges, and care for learning deficiencies or behavioral problems.*
10. Bills related to an event while on active military duty.
11. Bills that worker’s compensation insurance should cover.
12. Any injury or illness arising from any illegal activity.
13. Any charges where a third-party is responsible.
14. Bill irregularities:
    1. Charges not submitted within twelve (12) months from the date of service
    2. Additional information requested from the member or provider needs to be received by REDEEM within 12 months of service or 90 days from the date requested, whichever is later. 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.
    3. Excessive or unnecessary provider charges which includes afterhours, holiday, and weekend fees
       Note: See section VI.C. Permitted Sharing Levels and section III. B. Approved Sharing of Bills for more information.
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 and alcohol abuse treatment.
19. Medical marijuana.
20. Care for symptoms not related to a specifically diagnosable disease or injury, such as ongoing fatigue and malaise*
21. Psychological, emotional, or spiritual conditions.
22. 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.*
23. Procedures or surgery that are not medically necessary.
24. Weight management treatment or procedures.*
25. Consultations include but are not limited to dietary, diabetic, lactation, and genetic counseling.*
26. Custodial or Long-term care.*
27. Educational services and materials including but not limited to; Lamaze, breast feeding, and early childhood intervention.
28. Prophylactic (treatment intended to prevent disease) and preventive surgery without personal history of diagnosis and a doctor’s recommendation.*
29. Experimental treatment*
30. Birth control for the purpose of contraception.
31. Abortion.
32. Hearing aids.*
33. Dental or Vision services not related to medical injury or illness.*
34. Orthotics.*
35. 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.*
36. Sleep studies not related to a specific disease or disorder*
37. 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, like an abortion, or the complication itself is not shareable, like a routine dental problem arising from the treatment of a routine dental problem.
38. Transportation to appointments
39. Psychotropic medication*
40. Nutrition services*
41. Non-prescription (over-the-counter) drugs and medical supplies/equipment;*
42. Gym memberships*
43. Non-medical expenses*
44. Additional wellness visits beyond the one allowed per membership year in REDEEM Enhanced*
45. Routine, wellness visits and prevention screenings for REDEEM Essential*
46. Immunizations for REDEEM Essential*
47. Outpatient Prescriptions for REDEEM Essential*
48. Premiums for insurance products

Items with an asterisk (*) are eligible for sharing under FlexShare.

H. REDEEM SeniorSaver Sharing Limitations

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

1. REDEEM SeniorSaver members can share items covered by Medicare Parts A and B after Medicare first applies its coverage and the individual has met the AUA.
2. REDEEM SeniorSaver members can share prescription bills when they have Medicare Part D and only after Medicare applies its coverage and the individual has met the AUA.
3. A provider must purchase blood products for the REDEEM SeniorSaver member requiring a blood transfusion. Those costs are shareable.
4. Inpatient acute care hospitalization for REDEEM SeniorSaver members:
   1. Days 1-60: Medicare covers these costs.
   2. Days 61-150: Medicare covers a significant portion of costs, the balance is shareable.
   3. Days 151-beyond: Ineligible for sharing.

The exception to the above would be any bill related to services declared as not eligible for sharing in Section III.G.