A. CMS and FDA Approved Treatment
The cost of both CMS and FDA approved testing, treatments, and up to six months of FDA approved prescription drugs per eligible condition will be considered for sharing if they are FDA approved for treating that condition. They must be ordered by one of the following:
- Medical Doctor (M.D.)
- Doctor of Osteopathy (D.O.)
- Nurse Practitioner (N.P.)
- Physician’s Assistant (P.A.)
- Doctor of Podiatric Medicine (D.P.M.)
- Dentist (D.D.S. or D.M.D.)
- Midwife
- Licensed Midwife (L.M.) or Certified Professional Midwife (C.P.M.) - for maternity services only; services must be within state-defined scope of licensure
- Optometrist
These CMS and FDA approved tests and treatments are to be performed at one of the following:
- Hospital
- Surgery center
- Clinic
- Doctor’s office
- Diagnostic facility
For other locations to be considered, a pre-eligibility review is required.
To be considered for sharing, diagnosis and treatment are to be performed in the U.S. except in emergencies or when living abroad.
The provider must submit medical bills on a CMS 1500 or a UB and IB form (healthcare industry standard forms) to be considered for sharing.
B. Sharing During the First Month of Membership
Members are eligible to receive up to $50,000 of their Eligible Medical Bills shared during their first month of membership. Members who went from being under a parent(s) Member Household to an individual membership have no cap on the amount of Eligible Medical Bills that can be shared during the first month of individual membership. (see Section II. F.).
C. Determining Eligibility for Sharing
The eligibility of a medical bill for sharing is determined after medical services are rendered. Medical and lifestyle information help determine eligibility. Medical records from 36 months prior to membership will be needed. If Authorization to obtain medical records is not given or access to requested medical records is refused, the medical bill(s) cannot be shared.
D. Lifestyle
Members must follow the Christian lifestyle and agree to the Statement of Faith. This is essential for Eligible Medical Bills to be shared. Members who do not follow the Christian lifestyle will have their membership cancelled. Examples of behavior that can lead to non-sharing and/or cancellation of membership include, but are not limited to: the use of tobacco in any form, including the use of e-cigarettes, vaping or nicotine replacement, the use of Illegal Drugs, the abuse of drugs including legal drugs, such as alcohol, prescription and over-the-counter medications, sexual relations outside of Biblical Christian Marriage, and participation in activities that represent a willful disregard for personal safety.
E. Sharing for Members 65 and Older
Members who are eligible and qualify for Medicare Parts A and B must enroll in Medicare and transition to Medi-Share 65+.
When a Member has Medicare, Medi-Share will be secondary. Sharing of Eligible Medical Bills incurred on or after the first day of the month a Member turns 65 is based on the difference between the Medicare-allowable charges and the actual amounts paid by Medicare. The provider must submit a copy of the Medicare Explanation of Benefits and the CMS 1500, or UB and IB form.
F. Pre-Existing Medical Conditions or Related Conditions
A pre-existing medical condition is defined as signs/symptoms, testing, diagnosis, treatment, OR medication for a condition within 36 months prior to membership (based on medical records). A pre-existing medical condition will ONLY be eligible for sharing as follows:
- Up to $100,000 per Member per year (based on effective date) once the Member has been faithfully sharing for 36 consecutive months.
- Up to $500,000 per Member per year (based on effective date) once the Member has been sharing faithfully for 60 consecutive months.
The cost of prescription medications for pre-existing conditions is never eligible for sharing.
Any congenital condition will only be eligible for sharing at the above referenced amounts once the member has been faithfully sharing for 36 or 60 consecutive months respectively.
High blood pressure or cholesterol that is controlled through medication or lifestyle will not be considered a pre-existing medical condition for purposes of determining eligibility for future vascular events.
Where there has been a lapse in Membership, a condition will not be considered pre-existing if the first instance of the condition appeared during the previous Membership, unless the lapse was due to cancellation for non-sharing or lifestyle requirements. An exception would be maternity that occurred outside the current Membership period, which will not be eligible for sharing.
G. Pre-Eligibility Review for Medical Conditions Prior to Surgical/Medical Procedures
A Member can receive a preliminary determination of whether or not his or her proposed treatment appears to be eligible for sharing. This is done by requesting a medical review to determine if the condition or treatment/procedure is eligible for sharing per the member voted guidelines. To request a review, contact Member Services at (800) 264-2562. Final eligibility determination is always made after the medical bills are submitted for processing. It is possible a treatment that appeared to be eligible for sharing during the preliminary review will be determined to be ineligible if:
- New information or additional medical records are provided that make the treatment ineligible due to pre-existing condition(s).
- New information or additional medical records are provided that make the treatment ineligible due to lifestyle issue(s).
The number of days required to complete a preliminary review depends on the responsiveness of the providers who are asked to send in medical records.
H. Care Management and Cost Management Support
Engagement with Care and Cost Management is required for Members with significant medical needs and for Members with certain medical conditions like cancer, organ transplant or intensive care hospitalizations for support in understanding and interpreting options for medical care. Members should contact Member Services at (800) 264-2562.
I. Medical Conditions and Services Subject to Limited Sharing
Listed below are the treatments, medical conditions, procedures, and services with sharing stipulations:
- Ambulance or other medical transport services may be eligible for sharing when medically necessary or required for transportation between facilities. Pre-eligibility review is recommended for non-emergency medical transport.
- Annual Physicals for each member of the household are eligible for sharing for members who join or change AHP levels on or after September 1, 2020. Basic lab tests, limited to A1c test and lipid panel, are also eligible for sharing if recommended as part of the annual physical.
- Cardiac rehabilitation is eligible for sharing for up to 36 sessions following hospitalization for an eligible cardiac condition or a cardiac procedure such as angioplasty or stenting, when ordered by a qualified provider, if initial session begins within 6 months of cardiac event.
- Chiropractic care — In cases which have been diagnosed by a licensed physician (M.D. or D.O) and the Member is offered only a surgical option, a chiropractic resolution may be eligible for sharing in lieu of surgery. The Member’s physician must provide a case history, x-rays and a recommendation for chiropractic resolution. If approved, chiropractic care is limited to a maximum of 20 visits within a six week period. Tests ordered by a chiropractor are not eligible for sharing.
- Direct Primary Care (DPC) membership fees (up to $1,800 per year), are eligible for sharing for members on the 12,000 AHP level with DPC option. DPC membership fees will be applied to the AHP and are eligible for sharing once the AHP has been met. Members who select this option will utilize their DPC provider for annual physicals, clinical, and laboratory services in lieu of submitting those bills for sharing.
- Durable Medical Equipment (DME) is eligible for sharing if the DME is ordered by a qualified CMS approved provider for the treatment of an eligible need. DME will not be rented for more than 6 months. Alternatively, a one time purchase of DME may be eligible for sharing. In order to be eligible for sharing DME must be obtained from a CMS approved DME provider.
- Genetic testing is not eligible for sharing in most cases. Genetic testing will only be considered for sharing if not available through a patient assistance program and is required for the personal treatment of a diagnosed condition. If genetic testing is determined eligible for sharing, it will be shared at the Medicare allowable rate. Genetic screenings are not eligible for sharing.
- Home Care is limited to treatment related to an eligible need ordered by a qualified provider for Members who are homebound for that need. A copy of the provider’s order for the care must accompany the bill. Home Care services, including home hospice, are limited to 60 calendar days from the first date of service for Home Care.
- Non-hospital admissions In-patient admission to a skilled nursing facility, rehabilitation facility, long-term acute care facility, or in-patient hospice is eligible for sharing for 30 days if ordered by a qualified Provider for an eligible condition in order to provide care that would otherwise need to be provided in an acute care setting. Eligibility for more than one referral for the same diagnosis will require a case manager medical review.
- Outpatient speech therapy is eligible for sharing up to 10 visits if post-stroke, post-surgery, or post-trauma. Swallow therapy is eligible for up to 10 visits. A copy of the provider’s order or referral for treatment must accompany the bill.
- Physical Therapy (PT), Occupational Therapy (OT), and Osteopathic Manipulation Therapy (OMT) are eligible for sharing if performed by a licensed therapist (massage therapists are not eligible) or Doctor of Osteopathy, related to an eligible diagnosis, and ordered by a qualified provider (See Section VI.A) for up to 20 visits combined. A copy of the provider’s order or referral for treatment must accompany the bill. Eligibility for more than one referral for the same diagnosis will require medical review.
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Prescription drugs – Prescription medications, including maintenance medications, are eligible for sharing for six months from the date of diagnosis, per each new condition that is not pre-existing. This includes prescription drugs that may be dispensed, infused, injected, or administered by a Medical Doctor (M.D.), Doctor of Osteopathy (D.O.), Nurse Practitioner (N.P.), Physician Assistant (P.A.), or Doctor of Podiatric Medicine (D.P.M.). Exceptions may be made in the case of medications for cancer and transplant recipients.
A new medication for an existing condition does not restart the six-month timeline.
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. Use of Medi-Share preferred specialty pharmacy formulary and providers are required when applicable.
- Prostheses are eligible for sharing if ordered by a qualified Provider to treat an eligible need and meet CMS criteria. All prostheses require medical review. Only one prosthetic treatment plan per diagnosis is eligible for sharing. Replacement, repair and maintenance of prosthesis are not eligible for sharing. (See Glossary of Terms for definition of prosthesis and examples.).
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Psychiatric or primary care evaluation, as well as associated lab tests and medications, for mental illness related to an eligible medical condition, is eligible for sharing for six months per each new condition. Counseling and psychotherapy are not eligible for sharing.*
*Access to mental health counseling by phone or video is available through the Member Center.
- Sleep Apnea Studies are eligible for sharing if they are ordered by a qualified provider (Section VI.A) for an eligible need. Provider must submit case history with the recommendation for the sleep study. Sleep studies ordered for insomnia are not eligible for sharing.
- Telehealth and Virtual Office Appointments: Outpatient evaluation and management visit costs are eligible for sharing at the Medicare allowable rate if the visit occurs directly between the member and provider and is for an otherwise eligible service per the guidelines. Virtual physical/occupational therapy and annual wellness preventative visits are not eligible for sharing.
J. Medical Conditions and Services Not Eligible for Sharing
If a medical bill is related to a diagnosis, treatment or procedure that is ineligible for sharing in any way, that medical bill is also ineligible. Listed below are the treatments, medical conditions, procedures and services that are ineligible for sharing:
- Expenses related to non-Biblical lifestyles and choices – including, but not limited to:
- Abortion of a live fetus (baby)
- Alcohol and drug related injuries and illnesses
- Sexually transmitted diseases (STDs) including HIV – Exceptions include innocent transmission via transfusion, rape, work-related needle stick or sex within marriage
- Illegal acts – Any charges for a condition, disability or expense resulting from being engaged in an illegal occupation or the commission of or attempted commission of a crime
- Intentionally self-inflicted injuries (e.g. suicide or attempted suicide)
- Maternity expenses for children conceived out of wedlock with an exception for pregnancy resulting from rape
- Alternative Care including, but not limited to:
- Vitamins/Supplements without a diagnosis of a specific deficiency
- Acupuncture
- Services from unapproved providers
- Experimental or investigational treatments
- Integrative medicine
- Functional medicine
- Regenerative medicine
- Behavioral/Mental Health care – including, but not limited to:
- Psychiatric or psychological care*
- Special education charges
- Counseling or care for learning deficiencies or behavioral problems, whether or not associated with a manifest mental disorder or other disturbance (e.g. Attention Deficit Disorders or Autism)
*Access to mental health counseling by phone or video is available through the Member Center.
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Cosmetic procedures – including, but not limited to, breast augmentation, lift or reduction, body or facial contouring, scar revision, tattoo removal, electrolysis, cosmetic Botox.
Cosmetic breast reconstruction after breast cancer is eligible for sharing for the affected breast and the non-affected breast if recommended for purposes of symmetry and only if the breast cancer is eligible for sharing. Revisions of initial breast reconstructions are ineligible for sharing except in cases of infection, necrosis or treatment of lymphoma.
- Dental and periodontal services – including, but not limited to:
- Removal of wisdom teeth
- Orthodontic/oral surgery (exception for trauma within one year of diagnosis)
- Repair or replacement of dentures, bridges, and appliances
- Diagnosis and treatment of temporal mandibular joint (TMJ) dysfunction or disease related to the joint that connects the jaw to the skull. This includes, but is not limited to braces, splints, appliances or surgery of any type
- Complications or infections related to dental procedures
- Fertility/infertility care – including, but not limited to:
- Birth control procedures, such as IUD, and/or related supplies
- Infertility testing and treatment
- Sterilization or reversals (vasectomy and tubal ligation)
- Embryo donation or adoption
- Gender reassignment surgery or other treatment related to gender identity disorder, including but not limited to hormone treatment.
- Medication or treatment for sexual health or dysfunction
- Miscellaneous care
- Care for symptoms not related to a specifically diagnosable disease or injury, such as ongoing fatigue and malaise
- Counseling or consultation expenses including, but not limited to:
- Dietary counseling
- Diabetic counseling
- Lactation counseling
- Genetic counseling
- Custodial Care/Long-term Care
- Educational services and materials including, but not limited to:
- Lamaze classes
- Breast feeding classes
- Early childhood intervention
- Hearing aids
- Over-the-counter drugs and medical supplies/equipment. Supplies are defined as medical equipment which is disposable (requiring replacement within six months). This includes but is not limited to:
- Diabetic supplies
- Wound care supplies
- Ostomy supplies
- Custodial care supplies
- Missed appointment fees
- Podiatric Orthotics (shoe inserts)
- Veteran Administration care and treatment
- Weight control and management
- Routine and Preventive care—including, but not limited to, all well-patient care and screening tests and procedures, such as:*
- Physicals
- Immunizations and vaccinations
- Lab studies
- Screening mammograms
- Screening colonoscopy
- Vision Services and routine optometry care, including but not limited to:
- All services related to nearsighted/farsighted/astigmatism, including contacts and eyeglasses
- Refractive services
- Sleep studies not related to a specific disease or disorder, including but not limited to:
- Insomnia
- Hypersomnia
- Motorized locomotion equipment, and home modifications are not eligible for sharing
- Billing irregularities
- Delayed Submissions - Bills are to be received by Medi-Share within 12 months from the date of service to be considered for sharing. Reimbursement forms and proof of payment for DPC fees must be submitted within 12 months of the date for which the DPC fee applies. Additional information requested from the Member and/or provider needs to be received by Medi-Share within the 12 months of service or the 90 days from the date requested, whichever is greater.
- Improper Submissions - Bills are to be submitted by the provider following standard healthcare industry submission and coding guidelines. This is necessary for bills to be considered for sharing.
- Improperly coded or submitted bills will not be shared.
- Excessive or unnecessary provider charges are not eligible for sharing and are defined as:
- Charges greater than 200% of Medicare allowable rate for Professional services (excluding Anesthesia)
- Charges greater than 300% of Medicare allowable rate for Facility Bills and Anesthesia
- Charges greater than the 70th percentile of U&C for services with no Medicare Reimbursement rate
- Additional charges including but not limited to afterhours, holiday and weekend fees, that are not CMS approved
K. Conflicts of Interest
Medical bills will be ineligible for sharing if the provider or ordering provider is related to the Member by blood, marriage, or adoption or if the Member has a financial interest in the provider. If the member is a medical professional and orders his/her own testing/treatment, bills will be ineligible for sharing.
L. Extra Blessings
The Extra Blessings program is designed to assist members with eligible adoption expenses after two events (see Section VIII.) or significant bills that are ineligible for sharing because they exceed the sharing limits in these guidelines (for example, see Section VI.F. & Section IX.B.), including the maternity sharing limits (see Section VII.A.).
To be considered for Extra Blessings, the dates of service must occur after the member has been faithfully sharing for 12 months. If a condition is ineligible for sharing based on Sections VI. A., B., D., I., J., or K., it is not eligible for Extra Blessings.
Extra Blessings gifts are used to fund the eligible Extra Blessings needs up to 100% unless the needs exceed the Extra Blessings contributions, in which case they will be distributed on a pro-rated basis. At the end of each quarter, any Extra Blessings contributions remaining after all eligible pending Extra Blessings needs have been met may be used for general sharing.
M. Program Blessings
Members may qualify for public assistance or private benevolence programs. Those who use programs such as these will receive an incentive in the form of a share credit. This share credit is limited to only once per need (diagnosis) and requires additional information to be submitted within a year from the date the medical event occurred in order to be eligible. The maximum share credit per need (diagnosis) is 12 consecutive months and does not include any Administrative, Health Partnership, or bank fees.