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Guidelines - III.D Pre-existing Conditions

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 the Member Start Date. 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. Any pre-existing condition known to exist at the Member Start Date has a three-year waiting period from the Member Start Date for bill sharing outside of FlexShare. After this waiting period, sharing towards pre-existing conditions is up to $125,000 per member, per year. In the sixth year of membership and every year thereafter, this limit increases to $500,000.

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.