Guidelines - III. 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.
Routine & Wellness Visits (REDEEM Enhanced)
Immunizations (REDEEM Enhanced)
Preventative Screenings (REDEEM Enhanced)
Medical Care Outside of the United States
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
The approved REDEEM HealthShare telehealth provider is free and available through the Member Center and is not subject to your AUA or any applicable Co-Share. Telemedicine from other providers is subject to your AUA and any applicable Co-Share.
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.