Adherence to the Zion HealthShare Principles of Membership minimizes medical risks, encourages good health practices, and ensures member integrity and accountability. Our members must comply with certain requirements to maintain membership and remain eligible to participate in our medical cost sharing community.

Zion HealthShare members are expected to act with honor and integrity. Members should not falsify a sharing request, medical records, or use other deceptive practices. If a member abuses the trust of our community, their membership may be revoked or withdrawn.

All Zion HealthShare members must attest to the following statements:

1. I believe that a community of ethical, health-conscious people can most effectively care for one another by directly sharing the costs associated with each other’s healthcare needs. I acknowledge that Zion HealthShare affiliates itself with, and considers itself accountable to, a higher power. I recognize that Zion HealthShare welcomes members of all faiths.

2. I understand that Zion HealthShare is a benevolent organization, not an insurance entity, and that Zion HealthShare cannot guarantee payment of medical expenses.

3. I will practice good health measures and strive for a balanced lifestyle. I agree to abstain from the use of any illicit or illegal drugs and refrain from excessive alcohol consumption, acts which are harmful to the body. I understand that members who use tobacco will have an increased monthly contribution (per household membership) of $50.

4. I am obligated to care for my family. I believe that mental, physical, emotional, or other abuse of a family member, or any other person, is morally wrong. I am committed to always treating my family and others with care and respect.

5. I agree to submit to mediation followed by subsequent binding arbitration, if needed, for any instance of a dispute with Zion HealthShare or its affiliates.

Membership eligibility is primarily based on:

1. Adherence to the Zion HealthShare Principles of Membership.
2. Participation in the community by submitting monthly contributions.
3. Under the age of 65.
4. Residency in the United States or Puerto Rico.

After committing to these primary eligibility requirements, prospective members are eligible to join the Zion HealthShare community. Membership may begin on a date selected by the prospective member or specified by Zion HealthShare, known as the membership start date. The prospective member’s monthly contribution must be received within 15 days of the agreed-upon membership start date. Once the first monthly contribution has been received membership is considered active.

Commitment

Members commit to abide by a set of personal standards as outlined in our Principles of Membership. If a violation of the Principles of Membership is discovered through review of a member’s submitted medical records, all sharing for that member will be put on hold. This hold will begin on the date the violation was discovered or recorded. Notification of the hold and an explanation of the discovery will be issued to the member.

Members will have 30 days to submit documentation supporting compliance with the Principles of Membership. If submitted documentation does not satisfactorily demonstrate compliance, membership may be revoked. If membership is revoked due to a violation of the Principles of Membership, Zion HealthShare will not return the offending member’s contributions received prior to the date of revocation.

Participation Through Contributions

Members submit monthly contributions to participate in the medical cost sharing community. Direct members make their contributions directly with Zion HealthShare. Essential members make monthly contributions through their employer or DPC practice.

Participation in the medical cost sharing community is voluntary, but monthly contributions are required for active membership and sharing eligibility. Monthly contributions must be received no later than 30 days after the contribution date. If a monthly contribution is not received by the last day of the billing month, the membership will become inactive, and the member will be withdrawn from the medical cost sharing community.

Withdrawn members may reapply if they meet all eligibility requirements. Once the member reapplies and membership is reinstated by Zion HealthShare, the member will become eligible to participate in our medical cost sharing community. All sharing requests submitted after the membership is inactive and before reinstatement will be ineligible for member-to-member sharing, and any medical conditions existing before the member is reinstated will be considered pre-membership medical conditions.

Qualification

Applicants must meet all criteria in the Member Guidelines, Principles of Membership, and membership application form to qualify for membership. If, at any time, it is discovered that a member did not submit a complete membership enrollment form, membership may be retroactively withdrawn or revoked.

While member health status has no effect on eligibility for membership, there are sharing limits for some pre-membership medical conditions. Sharing requests that are not eligible for sharing may still be eligible through the Additional Giving fund. See the Additional Giving section for details.

Active Membership

Membership is considered active when the member has paid their monthly contributions on time and is in good standing with Zion HealthShare. For a sharing request to be shared, membership must be active during the date(s) of service, when medical bills are received, and when the IUA is paid. If a membership becomes inactive before a sharing determination is made, the bills may not be shared with the community. Any pre-membership medical condition limitations are applied based on the first date of active membership.

Residency Statement

Zion HealthShare members must reside within, and be a resident of, the United States or Puerto Rico to participate in and contribute to medical cost sharing. Members who choose to move outside of the United States or Puerto Rico for missions, military, or serving abroad can maintain their membership with the following requirements:

• Regular monthly contributions,
• Member(s) must have a physical address in the United States or Puerto Rico, and
• Cost sharing for medical care outside of the United States or Puerto Rico will follow the International Medical Treatment guidelines. That is, only acute and sudden onset medical expenses will be considered for sharing. Preventive, scheduled, or the like will not be considered for sharing.

Zion HealthShare is unable to enroll new members who reside in the state of Washington. See Zion HealthShare’s Washington Statement for more information.

Zion HealthShare offers different membership options for individuals and families. Monthly contributions are based on the membership type (Direct or Essential), age group, and initial unshareable amount (IUA).

Determination of Household Membership

There are four membership tiers:- Member Only: An individual member- Member & Spouse: Two married members or two members in a domestic partnership- Member & Child(ren): A member and any eligible children, without membership of a spouse or domestic partner- Member & Family: A member, spouse or domestic partner, and any children

Spouse/Domestic Partner

Domestic Partner is an unrelated and unmarried person who shares common living quarters with a Primary Member and lives in a relationship that is not legally defined as marriage by the state in which the member resides. A spouse is a significant other in a state-defined marriage. In certain contexts, it can also apply to a civil union or common-law marriage.

Child(ren)

An unmarried child under twenty-six (26) years of age, and any child born into a membership in connection with an eligible maternity sharing request, may participate under a household membership with the Primary Member. The Primary Member is responsible for ensuring that each individual participating under the household membership complies with the Member Guidelines and Principles of Membership.

When a child turns twenty-six (26) or marries, they can no longer participate under the household membership. To ensure a continuous membership, the child must complete an application form within thirty (30) days after being withdrawn from their previous household membership.

Children who age out of a membership and choose to re-enroll after the 30-day time limit, will be subject to the sharing limitations for pre-membership medical conditions. Any sharing requests that occur between the time a child is withdrawn from their previous membership and beginning their own are ineligible for sharing.

Newborns

Newborns whose birth is related to an eligible maternity sharing request must be added to the household membership by the parent within 30 days of birth. In the case of a membership tier change, the monthly contribution amount will automatically be adjusted for the next contribution. If the parent does not enroll their newborn within 30 days, any conditions present at birth or that occur before the child’s membership start date will be considered pre-membership medical conditions.

If a parent wishes to add a newborn who was not born in connection with an eligible maternity sharing request, the parent must submit a membership application form for the baby. The newborn’s membership start date can be no sooner than seven (7) days after delivery.

Any genetic conditions or complications for newborns not born in connection with an eligible maternity sharing request are considered pre-membership medical conditions and subject to the same limitations as defined in the Pre-Membership Medical Conditions section.

Adoption

Zion HealthShare considers adopted children the same as biological children. Any physical conditions the adoptive parents are aware of prior to the legal adoption of the child are considered pre-membership medical conditions and are subject to the sharing limitations and phase-in period as defined in the Pre-membership Medical Conditions section. Adopted children cannot be added to a Zion HealthShare membership prior to birth and must adhere to the waiting period as mentioned under the Newborn and Maternity Sections.

Grandchildren

A grandchild (or grandchildren) may be included as part of their grandparent’s membership under the following criteria:

1. The grandparent has legal custody of the grandchild.
2. The grandchild lives with their grandparents at least nine months out of the year.
3. There is no other group, agency, or person responsible for the grandchild’s medical needs.

Tobacco Users

Household memberships with one or more tobacco users, are required to contribute a higher monthly contribution to maintain membership. The monthly tobacco surcharge is $50 per household membership.

A tobacco user is defined as use of any tobacco product one or more times within the past twelve (12) months. Tobacco products include, but are not limited to, cigarettes, cigars, chewing tobacco, snuff, pipe tobacco, and inhaled products through vape, hookah, and similar delivery devices. Smoked cannabis products are considered tobacco for the purposes of the tobacco surcharge.

There will be a requirement of back payment for the tobacco surcharge if Zion HealthShare is made aware that a household membership has a tobacco user.

If the tobacco user(s) have not used tobacco products for over twelve (12) months, the tobacco surcharge may be removed by providing supporting documentation from the treating licensed medical provider to Zion HealthShare. However, the sharing limit will remain. Please refer to the Tobacco Use Over 50 section.

The initial unshareable amount, or IUA, is the amount a member must pay before expenses related to a medical need become eligible for sharing with the medical cost sharing community. We have three membership IUA options: $1,000, $2,500, and $5,000.

After the IUA is met, additional eligible medical expenses are eligible for sharing with the Zion HealthShare community. There is no annual or lifetime limit on eligible expenses. Members do not need to pay another IUA for any given sharing request until they are symptom free for 12 months. Additionally, household memberships will not be responsible for more than three (3) IUAs in a rolling 12-month period.

Note: Maternity sharing requests have a standard IUA as noted in the Maternity Section.

Changing IUA Amounts

Household memberships may choose to change their IUA once per membership year. If an IUA is lowered, a 60-day waiting period will apply to all sharing requests other than those resulting from an accident.

Multiple Sharing Requests in a 12-Month Period

We provide a safeguard for household memberships that experience more than three (3) sharing requests in a rolling 12-month period. Each household membership will only be responsible for three (3) IUAs in a rolling 12-month period beginning on the date the member submits the verified IUA. If a household membership has paid three (3) IUAs in a rolling 12-month period, any additional eligible sharing requests exceeding $500 will be shared with no IUA responsibility.

Sharing requests are submitted on a per member, per medical need basis. A medical need is the reason for which a member submits a sharing request. This includes, but is not limited to, preventive visits, maternity, an accident, or a serious medical incident. Each medical need may result in medical expenses incurred by receiving medically necessary treatment that is proven safe and effective from licensed medical professionals and facilities, such as physicians, emergency rooms, and hospital facilities.

When a member has a medical expense to be shared, the member must submit a sharing request. Once their sharing request is open, the member must submit original, itemized bills for the medical expense within six (6) months of treatment. Bills submitted more than six (6) months after the date of service may be considered ineligible for sharing. There is no lifetime limit on the number of eligible expenses that may be shared.

See the Sharing Request Guide for more information.

Submitting a Sharing Request

Sharing requests must be submitted through the Member Portal, as soon as possible, but no later than six (6) months from the date of service. Most nonemergency eligible sharing requests, such as surgical procedures and preventive, should be submitted prior to the date of service.

Determination of a Sharing Request

Expenses related to the same medical need, whether expenses for a single incident or separate incidents, will be shared as one sharing request. Members do not need to pay another IUA for any given sharing request until they are symptom free for 12 months. After 12 months, if symptoms return, a new sharing request will need to be opened and another IUA paid.

Required Documentation & Time Limit for Providing Documentation

In order to be eligible for sharing, sharing requests and each itemized bill and statement must be submitted within six (6) months of the date of service. The IUA must also be paid within six (6) months to be considered for sharing. When submitting a sharing request, members must submit any documentation received from their provider. Zion HealthShare may request additional documents that may be required throughout the sharing request process. Document types can include, but are not limited to, receipts, proofs of payment, itemized bills and statements.

Original, itemized bills and statements must be submitted promptly to Zion HealthShare along with the sharing request form, opened through the Member Portal, for us to process the sharing request as soon as possible.

Please reference all applicable guidelines to determine if there are other document requirements or time limits.

Meeting the IUA

Medical expenses are only eligible for sharing after members have met their IUA. Members must provide documentation to Zion HealthShare of all payments that may contribute toward the member’s IUA.

The IUA must be paid within six (6) months of the date of service or bills may become ineligible for sharing. Consideration will be given for situations where the cost of treatment has not exceeded the IUA after six (6) months for certain eligible sharing requests. Members must communicate with their Member Needs team representative about a timeline for IUA payment.

Paying at the Time of Service

Zion HealthShare is not insurance, so members should tell their provider they are an uninsured, self-pay patient if they do not have insurance through other means. That way, members can obtain self-pay discounts on services, which allows us to keep membership contributions low. Members must obtain itemized bills and receipts to request payment or reimbursement from Zion HealthShare. In some cases, prepayment may be an option.

Contact our Medical Advocacy team before receiving nonemergency medical treatment for prompt payment at the time of service.

Requesting Discounts

Members have options for sharing prior to, at the time of, or after medical services are rendered. For all purposes, members should present as self-pay patients and communicate costs and discounts as soon as possible to Zion HealthShare.

Insurance, Group Plan, Government Assistance Plans, or Legal Representation 

If you have other insurance, a group plan, or government assistance, or the like, those will be responsible for covering your medical expenses first. The Zion HealthShare community will only step in to share any remaining eligible medical expenses. If you’ve hired a lawyer to handle medical expenses related to a specific need or because of issues with medical services, Zion HealthShare will wait to see the outcome of your case before deciding if the community can share any leftover eligible medical expenses.

It’s important to let us know if you have any other coverage, including through a spouse, family member, employer, or government program. If you don’t disclose this information, your expenses may not be eligible for sharing.

Appeals

If a member believes that a sharing limitation was incorrectly placed or a determination of ineligible for sharing was provided on their sharing request, they may submit an appeal. Members may submit an appeal only if their membership remains active throughout the appeals process. All appeals are reviewed by a committee, which includes at least one Zion HealthShare board member, as well as trained medical professionals.  All appeals results are final and may not be appealed again.

Appeal requests must be submitted within thirty (30) days of the sharing request determination and must be submitted by the member, not the member’s providers. Zion HealthShare may request additional information from providers if needed.

To file an appeal, send the medical evidence, a written explanation, and any other supporting documentation to the Determination Adjudicators.

Aging Out at 65

Medical incidents, services, and expenses that occur prior to the members age-out at sixty-five (65), will have up to thirty (30) days after their membership end date to submit a sharing request. All other time limits will remain in effect including:- itemized bills and statements must be submitted within six (6) months of the date of service, and- the IUA must be paid within six (6) months of the initial date of service, or they become ineligible for sharing.

Medical Records Addendums

A member’s Medical Records may be requested to assist with the determination of a sharing request. After the requested medical records have been reviewed and a determination is made, medical record addendums will not be considered unless they are combined with an official addendum from the applicable provider. The addendum must be separate and include the following:

• signature from the applicable provider,
• date,
• description of what was changed, and
• reason for change.

Conflict of Interest

In keeping with the Principles of Membership, and in the interest of protecting the Zion HealthShare community, medical expenses incurred by a member that obtains medical treatment from a provider with which the member has an affiliation, partnership, personal or business relationship, or the like, and receives financial gain, is ineligible for sharing.

Maximum Shareable Amount

There is no annual or lifetime maximum for any member or household membership. However, some expenses may be subject to limitations according to these Member Guidelines.

To keep membership contributions low for all members, we implement a waiting period for sharing of medical conditions that existed prior to a member’s membership start date. We call such medical conditions: pre-membership medical conditions. This section defines pre-membership medical conditions and outlines related sharing limitations.

Definition of Pre-Membership Medical Condition

A pre-membership medical condition is anything where a member has experienced one or more of the following: 

• been examined,
• been diagnosed,
• taken medication,
• had symptoms,
• a personal history of or known increased risk of conditions that may arise or worsen in pregnancy, or
• received medical treatment within the 24 months prior to their membership start date. Sharing requests related to pre-membership medical conditions are only eligible for sharing if the condition was regarded as cured and did not require treatment or present symptoms for 24 months prior to the membership start date.

Pre-Membership Medical Condition Phase-In Period

Pre-membership medical conditions have a phase-in period wherein sharing is limited. Starting from the membership start date, there is a one-year waiting period before pre-membership medical conditions are eligible for sharing. After the waiting period, the amount eligible for sharing increases with each membership year.

Amounts eligible for sharing  for pre-membership medical conditions:- Year One: $0 (waiting period)- Year Two: $25,000 maximum per sharing request- Year Three: $50,000 maximum per sharing request- Year Four: $125,000 maximum per sharing request. After four years of membership, expenses related to pre-membership medical conditions will be eligible for sharing up to a maximum of $125,000 in a 12-month period. The maximum resets each membership year.

Exceptions for High Blood Pressure, High Cholesterol, & Diabetes

High blood pressure, high cholesterol, and diabetes (types 1 and 2) are not considered pre-membership medical conditions as long as:

1. the member has not been hospitalized for the condition in the 12 months prior to enrolling, and
2. the member is able to control the condition through medication or diet.

The following list reflects sharing limitations for certain conditions or requirements for certain expenses to become eligible. All expenses eligible for sharing are subject to the member’s IUA.

1. Alcohol & Drug Abuse Treatment

Sharing for alcohol and drug abuse treatment is available upon membership start date and is not considered a pre-membership medical condition. Treatment for alcohol abuse, substance abuse, or chemical dependency is only eligible for sharing up to $3,000 per member.

2. Ambulance Transport

Medical transportation, including air and ground, is eligible for sharing when it is required in relation to a specific illness or injury eligible for sharing. Every effort should be made to be transported to the closest appropriate facility.

3. Arthritis Treatment

Arthritic conditions, even if asymptomatic, are considered a pre-membership medical condition. Any treatment and/or procedure costs, including but not limited to joint injections, physical therapy, and chiropractic manipulations, are subject to the pre-membership medical condition phase-in period.

See Pre-Membership Medical Conditions Guidelines for more information.

4. Audiological

Audiological treatment to correct hearing loss is eligible for sharing.

5. Automobile Accidents

In the event of an automobile accident, Zion HealthShare will only consider sharing in medical expenses after any relevant insurers have processed claims and made final payments. This includes, but is not limited to, automobile insurance, health insurance policies, government assistance plans, workers compensation, or liability insurance.

Incidental insurance policies are not considered relevant for this purpose. These include but are not limited to accident, critical illness, and hospital indemnity coverage. Members must submit a sharing request within six (6) months of a medical need arising from the accident informing Zion HealthShare of any relevant insurers, upon which the relevant insurers will be primarily responsible for the payment of the member’s medical expenses. Any remaining expenses will be reviewed by Zion HealthShare for sharing eligibility.

Failure to disclose coverage with an insurance, group plan, government assistance plan, or legal representation may result in ineligibility for sharing. This includes, but is not limited to, any form of coverage through a non-member spouse, family member, employer, or government entity. If you have primary insurance coverage, Zion HealthShare will be the secondary payor, and some expenses not covered by insurance may be eligible for sharing.

6. Basal & Squamous Cell Cancer

Each individual location of a squamous cell or basal cell cancer requires a separate sharing request and separate IUA.

7. Cataract Surgery

Cataract surgery is treated as a pre-membership medical condition and subject to a one-year waiting period before it is eligible for sharing. Age-related cataracts requiring multiple procedures may be shared with one (1) IUA if the second procedure is completed within three (3) months of the first procedure. Non-age-related cataract surgery requiring multiple procedures that is considered eligible for sharing requires two (2) separate IUAs.

8. Congenital Conditions

Congenital conditions of children born outside an eligible maternity sharing request will be considered pre-membership medical conditions and therefore subject to the waiting period for sharing.

See the Maternity Sharing Requests section for more information.

9.  Contraception

Contraceptive costs are ineligible for sharing. This includes but is not limited to intrauterine devices (IUDs), implantable contraceptive methods, condoms, surgical sterilization procedures, and the Plan-B pill. Members can use Zion HealthShare’s discount program, Zion RxShare, for prescribed oral contraceptive medications that are available at a pharmacy.

Hormonal treatments and IUDs for non-contraceptive purposes may be eligible for sharing. 

10. Cosmetic Surgery

Expenses related to cosmetic surgery are eligible for sharing only for disfiguration due to a injury or illness eligible for sharing.

11. Degenerative Conditions

Degenerative conditions, even if asymptomatic, are generally considered a pre-membership medical condition and are subject to the applicable phase-in period. See Pre-Membership Medical Conditions Guidelines for more information.

12. Dilation & Curettage (D&C)

Dilation and curettage (D&C) procedures related to an eligible sharing request and indicated for diagnostic and therapeutic purposes are generally considered to be eligible for sharing. Elective dilation and curettage procedures are ineligible for sharing.

Please also refer to the Abortion section.

13. Durable Medical Equipment (DME)

Durable medical equipment (DME) is eligible for sharing if it is prescribed by a licensed medical provider and if it is related to an eligible sharing request.

Durable medical equipment can generally be rented, is reusable by other patients, is prescribed for a specific illness or injury, and can be used in the home. Some examples of DME are oxygen tanks, wheelchairs, walkers, crutches, canes, and hospital beds. Zion HealthShare encourages members to rent equipment when possible if the rental costs for the duration of the treatment are less than the purchase price. Sharing in the cost of purchasing DME requires prior written approval from Zion HealthShare. Sharing is limited to 120 days per medical need. Sleep apnea equipment is not shareable.

14. Emergency Visits

Emergency room (ER) visits are generally eligible for sharing, whether or not they are in conjunction with an eligible medical need. The first ER visit for a medical condition is treated as a normal sharing request. Each additional visit related to the same condition requires the member to take on a personal responsibility of $500 in addition to the member’s IUA. Members with nonemergency needs should seek out other treatment options such as doctor visits, telemedicine, urgent care clinics, or other appropriate care. Seeking proper nonemergency care reduces emergency room visits and the financial strain on the entire community.

15. Genetic Mutation

Sharing requests resulting from a genetic mutation that existed prior to membership start date are subject to the same limitations as other pre-membership medical conditions. If the member did not receive a diagnosis, require treatment, present symptoms, or take medication for the genetic mutation in the 24 months prior to membership start date, eligible sharing requests related to the condition may not be subject to pre-membership medical condition limitations.

16. Genetic Testing

Genetic testing will only be considered for sharing if it is required for the treatment of a eligible condition, such as breast cancer.

17. Home Healthcare

Home healthcare expenses are eligible for sharing when related to an eligible accident, illness, or injury and when a licensed physician has prescribed the care. Sharing of home healthcare expenses is limited to 30 days.

18. Hospice Care

Hospice care is eligible for sharing for 90-day periods with certification of terminal illness and when ordered by, and under the care of, a licensed medical professional.

19. Hyperbaric Therapy

Inpatient or outpatient hyperbaric therapy may be eligible for sharing for the treatment of a specific illness or injury. Outpatient hyperbaric therapy is shareable for up to 35 therapy sessions.

20. Injections

Injections related to an eligible sharing request are eligible for sharing up to $5,000. Hormone therapy injections related to an eligible sharing request are eligible for sharing up to $3,000. Injections related to gender transitioning or sex reassignment therapy are ineligible for sharing.

21. International Medical Treatment

Medical expenses for emergency and acute care incurred outside the United States or Puerto Rico will be considered for sharing based on the Member Guidelines. All other medical expenses are ineligible for sharing.

22. Joint Replacement Treatment

Joint replacement treatment and surgery for degenerative arthritis conditions may be eligible for sharing following the pre-membership conditions sharing limits.

23. Laboratory Tests & Checkups

Laboratory tests and checkups in relation to an eligible sharing request may be considered for sharing when prescribed by a licensed medical provider.

24. Long-Term Care & Skilled Nursing

Long-term care and skilled nursing are eligible for sharing when prescribed by a licensed medical provider for recovery from an eligible injury or illness.

25. Medical Supplies

Medical supplies that directly aid in the treatment of, or recovery from, an eligible medical need is generally able to be shared for up to 120 days from the treatment start date, as prescribed by a licensed medical provider. Medical supply costs must be over $100 per item to be considered for sharing, with a limit of $500 per eligible medical need. Zion HealthShare will share the retail costs (or fair market costs when applicable), and we encourage members to use vendors such as local pharmacies or medical supply stores.

Medical supplies are supplies that are disposable, not meant to be used by another patient, are meant for single use, or are meant for short-term use. Examples are joint stabilizing braces, urinary catheters, oxygen masks, and nasal cannulas.

26. Miscarriage

Miscarriage-related costs are generally eligible for sharing, subject to the chosen household membership’s Initial Unshareable Amount (IUA). Conception must occur on or after the membership start date; however, sharing is not subject to the six (6)-month maternity waiting period.

27. Nutritionists

Expenses related to nutritionist or dietician services are ineligible for sharing unless prescribed by a licensed medical provider and are limited to two (2) visits per eligible sharing request, specifically the initial and follow-up visit.

28. Occupational Therapy

Occupational therapy is eligible for sharing for inpatient treatment and up to 35 outpatient sessions per eligible sharing request, up to $7,500.

29. Organ Transplants

Organ transplants are eligible for sharing; however, they are subject to limitations for pre-membership medical conditions.

See Pre-Membership Medical Conditions Guidelines for more information.

30. Osteoporosis

Osteoporosis, even if asymptomatic, is considered a pre-membership medical condition and is subject to the sharing phase-in period. See Pre-Membership Medical Conditions Guidelines for more information.

31. Prescriptions

Prescription medications are considered eligible for sharing under the following conditions:

• The prescription is related to the treatment of an eligible sharing request.
• The prescription is ordered by a licensed provider.
• The prescription is approved by Zion HealthShare.

When these conditions are met, the member will be reimbursed for the cost or given a onetime use credit card for the exact cost of the prescription to take to the pharmacy and pay for their prescription.

Sharing in all prescription costs is limited to 12 months.

Prescriptions such as Eliquis, Humira, Stelara, and others, may be eligible for sharing under the above conditions. For all other prescriptions that do not meet the above conditions please use Zion RxShare. Please refer to their website for additional assistance.

32. Self-Referrals

Referrals not ordered by a licensed medical provider, or self-referrals, require review and approval for sharing by Zion HealthShare, including all deposits, retainers, or other payments a provider may require prior to scheduling an appointment. Referrals ordered by a licensed medical provider for additional consultation, or services directly related to an eligible medical need are generally considered to be eligible for sharing.

33. Speech Therapy

Speech therapy in relation to an eligible illness, injury, or accident is eligible for sharing for 35 outpatient visits per condition, up to $3,000. Speech therapy for conditions such as speech delays or learning impairments not caused by injury or accident is ineligible for sharing.

34. Sports

Medical expenses related to recreational sporting activities are generally eligible for sharing. Illness or injury resulting from practicing, or participating in, any semi-professional or professional competitive athletic contest for which the member receives any compensation is ineligible for sharing.

35. Suicide & Attempted Suicide

Zion HealthShare will share in expenses related to the suicide or attempted suicide of an adolescent, age eighteen (18) and under. Up to $25,000 may be shared after one (1) year of continuous membership.

If you or someone you know is experiencing suicidal thoughts or a crisis, please reach out immediately to the Suicide and Crisis Lifeline at 988 or text HOME to the Crisis Text Line at 741741. These services are free and confidential.

36. Therapeutic Treatments

When prescribed and performed by a licensed medical professional for a specific illness, injury, or disease to the musculoskeletal, and related to an eligible sharing request, expenses for therapeutic treatments are eligible for sharing up to either a maximum shareable amount of $7,500, or a maximum total of 35 treatments, per medical need. Once either the maximum shareable amount, or maximum total of 35 treatments has been exceeded, therapeutic treatments related to the medical need are ineligible for sharing.

Therapeutic services include, but are not limited to:

• Alternative and/or integrative therapies such as acupuncture, craniosacral therapy, dry needling, ozone treatments, prolotherapy, and alternative infusion therapies.
• Chiropractic treatments and services provided by licensed chiropractors.
• Massage therapy and services provided by licensed massage therapists.
• Physical therapy and services performed by licensed physical therapists.

When alternative or integrative medical practices are chosen by the member, sharing in the same medical need may be limited if the member decides to return to traditional care methods.

37. Tobacco Use over 50

Medical cost sharing for the eligible sharing requests of tobacco users 50 years of age and older is limited to $50,000 for each of the following four disease categories:

• Stroke
• Cancer
• Heart conditions
• Chronic obstructive pulmonary disease (COPD)

38. Varicose Veins

Evaluation and treatment for varicose veins may be eligible for sharing and is subject to the pre-membership medical condition sharing limits.

39. Weight Reduction

Expenses related to weight reduction are considered pre-membership medical conditions and are subject to the sharing phase-in period. Expenses are considered eligible for sharing if prescribed by a licensed medical provider and approved by Zion HealthShare, up to $3,000 per sharing request.

The Zion HealthShare medical cost sharing community chooses not to share in some medical expenses. Decisions for sharing eligibility are made to benefit all members by keeping monthly contributions low and sharing in medical expenses based on our Principles of Membership. The following expenses are excluded from sharing with the Zion HealthShare community.

1. Abortion

Expenses for the abortion of a living, unborn baby are ineligible for sharing.

2. ADHD & SPD Treatment

Expenses for evaluations, treatments, and prescriptions related to ADHD and SPD are ineligible for sharing. Members can use Zion HealthShare’s discount prescription program, Zion RxShare, for any prescribed medications that are available at a pharmacy.

3. Allergy Treatments

Allergy testing and medication is excluded from sharing. Members can take advantage of Zion RxShare to receive prescription discounts. Sharing requests related to non-seasonal allergies, such as an emergency room visit for an allergic reaction, may be considered for sharing.

4. Breast Implant Removal

Breast implant removal is ineligible for sharing.

5. Dental

Dental services, such as caps, crowns, root canals, fillings, wisdom tooth extraction, anesthesia, sedation, and cleanings are not shareable. Expenses related to devices including, but not limited to splints, bite guards, and expanders are ineligible for sharing.

Tooth damage caused by an accident or injury (e.g., car accident) and in relation to an eligible sharing request may be considered for sharing.

6. Diabetic Medication & Supplies

Any medical expenses related to supplies, testing, medication, or other implements used to treat diabetes are ineligible for sharing.

Please visit Zion RxShare for more information.

7. Fees & Interest

Any late payment fees or interest charges that may accrue to medical bills before a member meets their IUA are the member’s responsibility—they are ineligible for sharing, and do not count toward the IUA. Additionally, any late payment fees or interest charges caused by a member’s delay in providing necessary documentation to Zion HealthShare are ineligible for sharing. Credit card transaction fees associated with a payment by the member are ineligible for sharing.

8. Fertility

Expenses related to fertility evaluations and treatments are ineligible for sharing.

9. Genetic Screening

Genetic screenings and/or genetic counseling are ineligible for sharing.

10. Hearing Aids

Expenses related to hearing aids are ineligible for sharing.

11. Injuries Obtained from Certain Acts

Injuries or illnesses resulting from a criminal act, euthanasia, assisted suicide, participation in a riot, or other such acts that would violate the Principles of Membership are ineligible for sharing.

Injuries or illnesses resulting from being under the influence of alcohol or drugs while committing a criminal act, such as operating a motor vehicle while impaired, are ineligible for sharing.

12. Medical Noncompliance

Failure or refusal to comply with a licensed medical professional’s treatment plan or leaving a facility against medical advice (AMA) may result in ineligibility of the sharing request and any complications that arise.

13. Medically Stable & Chronic Conditions

An eligible medical need may be considered medically stable when the condition is chronic and further treatment will not likely result in improvement. At this point, the sharing request is subject to review and may result in determination of ineligibility for future sharing.

14. Mental Health

Expenses related to medications or other treatment for any mental health illness or condition are ineligible for sharing. Mental health conditions may include anxiety, depression, mental illnesses, and other psychological conditions. Through Primestin Care, Zion HealthShare members may have access to mental health resources including acute counseling sessions. Refer to the Virtual Care Guidelines on the Primestin Care website for more information. Primestin Care is available as an additional service to any household membership. Members can use Zion HealthShare’s discount prescription program, Zion RxShare, for any prescribed medications that are available at a pharmacy.

15. Sleep Apnea

Sleep apnea equipment and testing are ineligible for sharing.

16. Sterilization

Elective sterilization, such as tubal ligation and vasectomy, is ineligible for sharing.

17. Subscriptions

Expenses related to subscriptions for Direct Primary Care’s (DPC), gym memberships, chiropractor memberships, or anything similar are ineligible for sharing.

18. Surrogacy

Expenses related to a surrogate pregnancy, whether or not the surrogate is a member, are ineligible for sharing.

19. TMJ (Temporomandibular Disorder)

Expenses related to evaluation and treatment of Temporomandibular Disorder, TMJ and other similar conditions are ineligible for sharing.

20. Vision

Vision expenses related to hardware, such as glasses and contacts, are ineligible for sharing. Expenses to correct refraction, including but not limited to Lasik, PRK, lens implants, and/or other surgical or non-surgical visual acuity procedures and treatments not related to cataract surgery, are also ineligible for sharing.

21. Vitamins & Supplements

The cost of vitamins and supplements is ineligible for sharing.

Zion HealthShare shares specific preventive services with the Direct Membership or with the additional Preventive Sharing service added to the Essential Membership for six (6) months. Preventive sharing is not subject to the IUA. Members should take advantage of the Medical Advocacy service as it is a complimentary resource to help them locate low-cost facilities.

Zion HealthShare references the following resources regarding preventive sharing:

• US Preventive Services Task Force
• American Cancer Society
• Centers for Disease Control (CDC) and Prevention Guidelines
• American Academy of Pediatrics
• American Academy of Family Physicians

Annual Provider Visit

Sharing for an annual provider visit is available upon membership start date and every twelve (12) months from the eligible visit date. Sharing is limited to the services provided during the office visit only, up to $175.

Cervical cancer screenings are considered eligible for sharing only when performed during the annual provider visit. Prostate cancer screenings by blood tests for prostate specific antigen (PSA) are considered eligible for sharing only when ordered or drawn during the annual provider visit and after fifty (50) years of age. If a follow-up is requested for either, it will require a separate sharing request and subsequent IUA.

Please note: Emergency room or urgent care visits are not eligible for sharing as an Annual Provider Visit.

Colorectal Cancer Screenings

Sharing for a colorectal cancer screening is available every ten (10) years beginning at the age of forty-five (45) and after six (6) months of a continuous membership that includes the Preventive Services additional service.

Sharing is limited to $5,000 for the screening colonoscopy, anesthesia, diagnostic testing, biopsies, and pathology performed as a part of the screening. Any additional costs, services, or follow-ups will be the member’s responsibility. For high-risk members under forty-five (45), this service may be eligible for sharing with prior written approval from Zion HealthShare.

Home colorectal cancer screening tests such as high sensitivity gFOBT (guaiac fecal occult blood test), FIT (fecal immunochemical test), and sDNA-FIT (stool DNA with fecal immunochemical test) are eligible for sharing beginning at the age of 45 and after six (6) months of continuous membership with preventive services. gFOBT and FIT are eligible for sharing once every twelve (12) months; sDNA-FIT is eligible for sharing once every three (3) years up to $500 for the test.

Any additional testing resulting from a home colorectal cancer screening test, including a colonoscopy, will require a separate sharing request and is subject to the IUA. All other colorectal cancer screenings are ineligible for sharing as a preventive service but may be considered for sharing as a separate sharing request dependent upon the reason and only with prior written approval from Zion HealthShare. All non-preventive colorectal cancer screenings are subject to the IUA.

Mammograms

Sharing for a mammogram is available after six (6) months of a continuous membership that includes the Preventive Sharing additional service and every year beginning at the age of forty (40). Sharing is limited to $600 for a 2D or 3D mammogram. The exam, appointment, and evaluation of imaging performed as a part of the screening will count toward the $600 limit. Any extra services provided will be the member’s responsibility. For high-risk members under the age of forty (40) this service may be considered for sharing with prior written approval from Zion HealthShare.

If the finding of the screening mammogram is inconclusive and warrants an ultrasound ordered by a licensed medical provider, Zion HealthShare will consider sharing in the cost which will be included in the $600 sharing limit.

All other mammograms are ineligible for sharing as a preventive service but may be considered for sharing as a separate sharing request dependent upon the reason and only with prior written approval from Zion HealthShare. All non-preventive and diagnostic mammograms are subject to the IUA.

Youth Immunizations

Sharing for youth immunizations is available upon membership start date for members born in connection with an eligible maternity sharing request, and after six (6) months of a continuous membership that includes the Preventive Services additional feature for all other members up to the age of eighteen (18).

Zion HealthShare may share up to the CDC price list in effect at the time of the eligible sharing request. Sharing is limited to the immunizations outlined below:

– HPV (Human Papilloma Virus)
– Men (Meningococcal)
– PCV (Pneumococcal)
– RV (Rotavirus Immunization)
– IPV (Inactivated Polio Immunization)
– HIB (Haemophilus Influenza Type B)
– Hep A (Hepatitis A)
– Hep B (Hepatitis B)
– VAR (Varicella)
– DTaP (Diphtheria, Tetanus, acellular pertussis)
– Tdap (Tetanus, Diphtheria, acellular pertussis)
– MMR (Measles, Mumps, Rubella)

Well Child Visits

Sharing for well-child visits is available upon membership start date for members born in connection with an eligible maternity sharing request and after six (6) months of a continuous membership that includes the Preventive Services additional feature for all other members. Sharing is limited to $175 for the office visit costs, and associated immunizations are limited as outlined in the Youth Immunizations section. Qualifying visits are for children at the following ages:

• Birth
• 1 Month
• 2 Months
• 4 Months
• 6 Months
• 9 Months
• 12 Months
• 15 Months
• 18 Months
• 24 Months
• 30 Months
• 36 Months

General

Maternity sharing requests have a structured Initial Unshareable Amount (IUA) as follows:

• Household Membership IUA: $1,000 — Standard Maternity IUA: $2,500
• Household Membership IUA: $2,500 — Standard Maternity IUA: $2,500
• Household Membership IUA: $5,000 — Standard Maternity IUA: $5,000

Expenses eligible for sharing may include prenatal care, postnatal care, and delivery. Any newborn expenses incurred after delivery are subject to a separate sharing request and IUA.

The maternity sharing request must be submitted no later than six (6) months from the initial date of service. Sharing requests submitted after that date will be considered ineligible for sharing.

Once the maternity sharing request is open, submittal of original, itemized bills for the medical expense(s) must be within six (6) months of service. Bills submitted more than six (6) months after the date of service may be considered ineligible for sharing.

Waiting Period

Maternity sharing requests are ineligible for sharing during the first six (6) months of membership. To be eligible for sharing, the conception date must occur after six (6) months of continuous membership, as confirmed by medical records. Members who intentionally misrepresent their conception dates may be subject to membership revocation.

Note: Household memberships with a start date before April 1, 2025, are NOT subject to the six (6)-month waiting period, but conception must still occur after the membership start date. Likewise, household memberships enrolled through a company or employer are also NOT subject to the six (6)-month waiting period.

Newborns who are not born in connection with an eligible maternity sharing request may be added to a household membership by calling or emailing Zion HealthShare. The newborn’s membership start date can be no sooner than seven (7) days after delivery, if not born in connection with an eligible maternity sharing request. Any complications that the newborn may have, or any medical conditions present at birth, will be considered pre-membership medical conditions.

See the Pre-membership Medical Condition section for details.

Eligible for Sharing

Prenatal

• Routine office visits
• Routine lab work
• Immunizations must be ordered by a licensed practitioner and is subject to the CDC Pricing List:
  • RSV: One dose ordered as part of routine prenatal care for women in their third trimester during the months of September through January. 
  • Tdap: Ordered for women between 27 and 36 weeks, only.
• Fetal non-stress test (after 36 weeks)
• Up to three standard ultrasounds (unless an unexpected complication requires additional scans)
• STD/STI screenings prescribed by a licensed practitioner as part of routine prenatal care

Delivery

• Ob-gyn labor and delivery
• Cesarean
• Multiple births
• Hospital labor and delivery
• Hospital room and board
• Anesthesiologist
• Nitrous Oxide: Must use FDA approved devices, cannot be combined with or also receive an epidural, and a sharing limit of $400.
• Home births
• Maternal fetal medical specialist consultations, when ordered by the medical provider managing the pregnancy.
• Pelvic manipulation is only eligible for sharing if there is a new onset of back and/or pelvic pain, after the 30th week, and with a total of 20 visits but no more than $2000, whichever occurs first. Exceptions will be considered for multiple births. Pelvic manipulation will no longer be shareable with the eligible maternity request after the date of delivery.
• Birthing centers
• Charges related to unexpected complications for the mother
• One in-hospital pediatrician visit, including routine immunizations, routine lab work, and routine hearing tests (all eligible for sharing when the baby is added to the household membership within 30 days of delivery and when these services occur prior to discharge from hospital)

Postnatal

• Mother’s six (6)-week postpartum checkup with pap test
• Two-week cesarean post-op appointment

Ineligible for Sharing

Prenatal

• 3D and 4D ultrasounds
• Most immunizations (such as flu shots)
• Non-prescription supplements
• Chiropractic services for babies in breach positions
• Genetic testing/counseling, including but not limited to:- Amniocentesis- Inhibin A- Alpha-Fetoprotein Serum (AFP)- Any type of Nuchal Translucency (NT) ultrasound- NIPT testing- Services by companies providing genetic testing

Delivery

• Doula services
• Birthing tubs
• Placenta encapsulations
• Circumcision
• Diagnostic hearing screening (including evoked auditory tests, BAEP, ABR, or BAER)

Postnatal

• Breast pumps
• Lactation consultant
• Mother’s immunizations
• Postpartum counseling
• Additional postpartum services

Other services may be ineligible or eligible as determined by Zion HealthShare. If you have questions about a specific service, please contact the Maternity department prior to receiving care. All genetic testing will be the responsibility of the member.

Checkups for the baby after delivery are not part of the maternity sharing request. If the newborn has any complications, they will require a separate sharing request. All of the baby’s checkups and any complications are subject to eligibility determination based on the Member Guidelines.

Midwives

Legally practicing midwifery costs are generally considered eligible for sharing but are subject to a $7,000 limit. Not all midwifery services may be eligible for sharing, and any expenses exceeding the $7,000 limit will be the member’s responsibility.

Home Births

Home births are generally considered eligible for sharing with the chosen household membership’s Initial Unshareable Amount (IUA).

If care becomes co-managed with a physician, complications arise, or delivery occurs in a hospital, the standard maternity IUA will be required before the Zion HealthShare community contributes to any remaining eligible expenses.

• Household Membership IUA: $1,000 — Standard Maternity IUA: $2,500
• Household Membership IUA: $2,500 — Standard Maternity IUA: $2,500
• Household Membership IUA: $5,000 — Standard Maternity IUA: $5,000

Separate Sharing Requests

Any complication for the newborn occurring after birth, whether the complication existed before or after birth (including congenital conditions), is separate from the mother’s eligible maternity sharing request and will require its own sharing request and IUA (in the event of a multiple birth, complications, each individual newborn will require their own sharing request and IUA).

Expenses for any pregnancy or birth-related complications of the mother are eligible for sharing as part of the eligible maternity sharing request.

Premature Birth

Any services outside standard maternity and newborn care would be considered a separate medical need for the baby and will require a new sharing request submission and new IUA.

In Vitro Fertilization (IVF)

Expenses related to fertility treatments are ineligible for sharing. For pregnancies occurring by IVF or other non-traditional fertilization methods, Zion HealthShare defines date of conception as the date the fertilized embryo is implanted in the uterus.

Gestational Diabetes

Gestational diabetes is considered a complication of pregnancy, and members who develop this condition are encouraged to follow the recommendations of their treating providers. Gestational diabetes is not considered insulin dependent. Therefore, costs of medications prescribed to treat gestational diabetes, including insulin, can be shared according to our prescription sharing guidelines.

Members are encouraged to seek counsel from their ob-gyn on dietary changes and exercise. Glucometers and test strips can be purchased at local pharmacies or online at reasonable costs. For these reasons, nutritionists, other therapists, and testing supplies are ineligible for sharing.

The Additional Giving fund is made of voluntary contributions from members of our medical cost-sharing community, and the generous donations of others, for the purpose of supporting other members who have medical expenses ineligible for sharing. The request and expenses must align with the Principles of Membership and may be considered for sharing from the Additional Giving fund. The allocation of these funds is decided on a case-by-case basis by the Additional Giving Committee.

Members are encouraged to give funds in addition to their standard monthly contributions. One hundred percent of Additional Giving contributions are placed in the Additional Giving fund, which is used solely to assist members who have a sharing request that is determined ineligible for sharing. Additional Giving funds are not subject to any administrative costs. Additional Giving is not mandatory, and members may contribute however much they feel is appropriate.

All members who adhere to the Principles of Membership are eligible to apply for assistance through the Additional Giving fund via an Additional Giving sharing request. Members may apply when they have an ineligible sharing request and have been active members for a minimum of three (3) months.

Guidelines for Additional Giving

Sharing requests that align with the Principles of Membership but do not meet the Member Guidelines may be eligible for sharing through the Additional Giving fund.- Members and other contributors may give additional funds to share with the community or give toward a specific sharing request.- Members are encouraged to share out of their surplus.- Members looking to request sharing from the Additional Giving fund must still meet their IUA before the sharing request becomes eligible for sharing.- Members who apply for sharing from the Additional Giving fund may only have part of their costs shared.

If a member dies after one year of uninterrupted membership, the Zion HealthShare community may provide financial assistance after receiving a copy of the death certificate. The surviving family may receive $10,000 per deceased member.

The surviving family must notify Zion HealthShare of the member’s passing within 60 days by providing the death certificate. The individual membership can be canceled and does not need to stay active to receive the End of Life Assistance or remaining sharing. Any remaining eligible medical expenses must be submitted to Zion HealthShare within 90 days of the death for review of sharing. Expenses submitted after 90 days will not be eligible for sharing.

Members (including a spouse or adult child) may withdraw their individual membership, completely or from a specific household membership, at any time. All requests may take up to the following business day to be processed, including those that take place on a holiday or weekend. To avoid being charged for the next billing cycle, membership withdrawal requests must be submitted at least 24 hours in advance. The membership will remain active until the
end of the household membership’s current billing cycle. Zion HealthShare cannot backdate withdrawals and therefore does not prorate withdrawals or provide refunds. Requests for membership withdrawal must be made in writing to Member Support Admin. The request must include (1) the members’ full name and date of birth, (2) the reason for withdrawal and (3) the requested withdrawal date. Only the primary member may remove other members from the membership. Once a membership is withdrawn any open sharing requests and all future sharing requests will no longer be eligible for sharing (unless the membership is reinstated before thirty (30) days). Members should plan accordingly

Note: If your membership is administered through your employer, a group plan, or any entity other than directly through Zion HealthShare, you must reach out to your employer, TPA, or the like’s representative to withdraw.

Zion HealthShare is not an insurance company. Neither this publication nor membership in Zion HealthShare are issued or offered by an insurance company. The purpose of the Member Guidelines is to help members understand and identify medical needs that may qualify for member sharing and the process by which member-to-member sharing is facilitated. The Member Guidelines are not for the purpose of defining the amounts that Zion HealthShare community will reimburse or share into. While the Zion HealthShare community has shared in all eligible member sharing requests to date, membership does not guarantee or promise that all eligible sharing requests will be shared. Rather, membership in the Zion HealthShare community merely guarantees the opportunity for members to share the financial burden in another member’s time of need. The financial assistance members receive will come from other members’ monthly contributions and not from Zion HealthShare.

THIS PUBLICATION AND MEMBERSHIP IN ZION HEALTHSHARE SHOULD NEVER BE CONSIDERED A SUBSTITUTE FOR A HEALTH INSURANCE POLICY. IF THE COST-SHARING COMMUNITY IS UNABLE TO SHARE ALL OR PART OF A MEMBER’S ELIGIBLE MEDICAL SHARING REQUEST, THE MEMBER WILL REMAIN SOLELY FINANCIALLY LIABLE FOR ANY AND ALL UNPAID MEDICAL EXPENSES. THESE GUIDELINES DO NOT CREATE A LEGALLY ENFORCEABLE CONTRACT BETWEEN ZION HEALTHSHARE AND ANY OF ITS MEMBERS. NEITHER THESE GUIDELINES NOR ANY OTHER ARRANGEMENTS BETWEEN MEMBERS AND ZION HEALTHSHARE CREATE ANY RIGHTS FOR ANY MEMBER AS A RECIPROCAL BENEFICIARY, A THIRD-PARTY BENEFICIARY, OR OTHERWISE. AN EXCEPTION TO A SPECIFIC PROVISION OF THESE GUIDELINES ONLY MODIFIES THAT PARTICULAR PROVISION AND DOES NOT SUPERSEDE OR VOID ANY OTHER PROVISION. THE DECISION BY ZION HEALTHSHARE TO REIMBURSE A MEMBER’S ELIGIBLE SHARING REQUEST DOES NOT AND SHALL NOT CONSTITUTE A WAIVER OF THIS PROVISION OR ESTABLISH BY ESTOPPEL OR ANY OTHER MEANS ANY OBLIGATION ON THE PART OF ZION HEALTHSHARE TO REIMBURSE A MEMBER’S ELIGIBLE SHARING REQUEST. TO SEE YOUR STATE NOTICE AND REGULATIONS PLEASE VISIT OUR WEBITE.

Visit https://zionhealthshare.org/disclosures/state-notices/ for your state specific notice.