Medical bills for specific conditions might be eligible for sharing, depending on a member's Annual Unshared Amount (AUA), co-share amounts, and other applicable conditions. Refer to each category below for detailed information.
1. Pre-existing conditions: Pre-existing medical conditions are defined as conditions in which known signs, symptoms, testing, treatment, diagnosis, or use of medication occurred within 36 months prior to the member’s start date. Routine or maintenance medications are considered treatment and are included in this definition, based on medical records. Testing for the purpose of monitoring a prior resolved condition will not be counted for pre-existing conditions so long as the tests indicate the continued resolution of the issue. Any pre-existing condition known to exist at the start of membership has a three-year waiting period from the start of membership for bill sharing outside of Flexshare. After this waiting period, up to $125,000 will be shared per member per year towards pre-existing conditions. In the sixth year of membership, this limit increases to $500,000
a. Adoption: Any physical condition of which the adopting parents had reason to be aware that the adopted child had prior to the adopting parents being legally responsible for the child’s expenses, or prior to his effective date within his parents’ membership, will be considered a pre-existing condition
b. Exceptions:
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Heart and Cancer Conditions: Bills for pre-existing heart and cancer conditions are subject to a five-year waiting period from time of membership. After this waiting period, the sharing limits in III.D.1 will apply. This waiting period will not apply to a new heart or cancer condition that occurs after membership begins.
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Type 1 Diabetes: Bills for pre-existing type 1 diabetes are not eligible for sharing.
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High Blood Pressure: Bills for pre-existing high blood pressure can be shared provided the member has not received hospital treatment for high blood pressure in the last five years, and the condition is controlled through medication or diet.
- Elevated Cholesterol: Elevated cholesterol alone is not considered a pre-existing condition, even if a statin is prescribed. However, if the statin is prescribed for a pre-existing condition such as arteriosclerosis, it will be considered pre-existing.
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c. FlexShare Submission: Pre-existing conditions can be submitted for FlexShare once the initial six-month waiting period for Flexshare has elapsed.
2. Maternity and Newborns
a. 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, based on medical records. This 12-month waiting period also restarts after a switch from
Essential to Enhanced or to a lower AUA.
b. Services Eligible for Sharing
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Antepartum care
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Labor and delivery
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Postpartum care
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Well-baby visits for the first three years are sharable if the membership has been part of REDEEM Enhanced for 12 months prior to the delivery date. These services are not subject to the AUA or co-share amounts.
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c. Adding Newborns to Membership
The baby must be added to the membership within 30 days of delivery to be considered a member from birth.
d. Birth Defects and Conditions
Any known birth defects or conditions in the baby from a preexisting maternity are not eligible for sharing. If birth defects or conditions are discovered after the mother
joins, these will be sharable after the AUA is met.
e. Approved Providers for Delivery
1. Medical doctor (MD)
2. Doctor of Osteopathy (DO)
3. Certified midwife
f. Ectopic Pregnancies
1. 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.
2. 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.
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Prescriptions
a. Inpatient Prescriptions
Eligibility:
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Prescriptions administered as part of inpatient treatment are sharable.
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These are subject to the Annual Unshared Amount (AUA) and co-share amounts.
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Sharing is up to the $1 million annual maximum shareable amount.
b. Outpatient Prescriptions
Enhanced program:
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Outpatient prescriptions are sharable only within the Enhanced program.
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There is an annual cap of $1000 per household per year.
c. FlexShare Submissions
All Other Prescription Costs:
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Any prescription costs not shareable under the above categories can be submitted to FlexShare.
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Routine & Wellness Visits
Routine and wellness visits are eligible for sharing only if the member is part of the REDEEM Enhanced program.
Frequency: Each member is eligible for one routine visit per year, which includes wellness gynecological visits.
Cap: Routine visits are capped at $300 per person per year.
Routine visit costs are not subject to the Annual Unshared Amount (AUA) and co-share amounts.
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Immunizations
Immunizations and the associated office visit are sharable for children who are members of REDEEM Enhanced from birth until two years of age. The cost of vaccinations may be shared for children who are members of REDEEM Enhanced between the ages of three and six as part of the child’s annual routine visit subject to the $300 annual per member cap.
Immunization costs are not subject to the AUA and co-share amounts.
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Preventative Screenings
Preventative screenings are limited to the screenings listed below. These are only eligible for sharing if the member is part of the REDEEM Enhanced program and are subject to the following conditions:
Mammograms
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One mammogram per year beginning at age 45.
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Not subject to the Annual Unshared Amount (AUA).
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Not eligible for sharing within the first 6 months of membership.
Prostate-Specific Antigen Test (PSA)
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One PSA test per year beginning at age 45.
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Not subject to the Annual Unshared Amount (AUA).
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Not eligible for sharing within the first 6 months of membership.
Colonoscopy
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One colonoscopy every 5 years per person or every 2 years for high-risk individuals (as determined by their physician), beginning at age 45.
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Cologuard (or equivalent testing) may be substituted for a scheduled colonoscopy if desired.
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Not subject to the Annual Unshared Amount (AUA)
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Not eligible for sharing within the first 6 months of membership.
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Mental Health
Cost for involuntary commitment up to $50,000 per year is sharable and subject to AUA and co-share.
Otherwise shareable only through FlexShare.
8. Therapies
There is a $5,000 cap per membership per year for the following therapies and treatments:
a. Vision
b. Cardiac
c. Respiratory
d. Physical therapy
e. Occupational therapy
f. Speech therapy
g. Hormone therapy
h. Injections
i. Chiropractic care
These therapies and treatments are subject to the Annual\ Unshared Amount (AUA) and co-share amounts. They must not
be for pre-existing conditions.
9. Motor Vehicles
Medical bills incurred for injuries resulting from motorized vehicles will only be eligible for sharing after any insurance entity or other liable third party has paid their portion, provided all other Guideline requirements are met. If the member was operating the vehicle, the vehicle must not have been operated recklessly.
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Medical Transportation
Ground: Eligible for sharing if medically necessary in emergencies. Subject to AUA and Co-share amounts.
Air: Eligible for sharing if medically necessary in emergencies. Subject to AUA and Co-share amounts.
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Telemedicine
Urgent care telemedicine conducted using our approved telehealth provider is freely available through the Member Center and is not subject to the AUA and co-share. Other telehealth visits will not be eligible for sharing.
12. Hospice Care
Hospice care services will be shared for 90 days upon prescription by a physician or certification that the person is terminally ill. Additional 90-day periods will be shared with a renewed prescription/certification subject to the per-year dollar maximum. If the member is in our Senior Saver program, then Medicare must provide their coverage first before any noncovered portions can be shareable by Redeem members.
13. Skilled Nursing Facility
Skilled Nursing Facilities are shareable for up to $10,000 per person per year once AUAs have been met for a shareable condition.