Guidelines - III.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.