Guidelines - 3.11 Not Eligible for Sharing
2026-07-01
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.