Member needs not associated with a prior medical condition are generally shareable. The following list reflects limitations on sharing. All shareable expenses are subject to the member’s IUA.
Expenses for the abortion of a living, unborn baby are not shareable.
ADHD, ADHS, And SPD Treatment
Expenses for prescriptions related to ADHD, ADHS, and SPD are not shareable. Members can use Zion Health’s discount prescription program, Rx Share, for any prescribed medications that are available at a pharmacy.
Allergy testing and medication is excluded from sharing. Members can take advantage of Rx Share program to receive prescription discounts. Needs that arise out of non-seasonal allergies, such as an emergency room visit for an allergic reaction, are considered shareable.
Alternative Medical Practices
Alternative medical treatments may be shared with the Zion Health community with prior written approval from Zion Health. To be considered a viable alternative to a traditional treatment plan, these treatments must be considered safe and effective. A member is also required to demonstrate the proposed value of the alternative treatment.
What is needed for Zion Health to consider an alternative medical need?
• Explanation of why the alternative medical need was selected
• Explanation of why the alternative medical need should be shared
• Doctor notes on current condition (Zion Health can help obtain doctor notes)
• Estimated costs (Zion Health can help obtain the estimated costs, if appropriate)
Zion Health considers alternative medical treatment plans on an individual basis and may put a cap on visits or shareable costs depending on the service.
Alcohol And Drug Abuse Treatment
Treatment for alcohol abuse, substance abuse, or chemical dependency is shareable up to $3,000 per member.
Ambulance transports are shareable as part of a need when they are required in relation to a specific shareable illness or injury.
Audiological needs to correct hearing loss are shareable. However, expenses related to hearing aids are not shareable.
Needs arising from an automobile accident are only shareable when a third party or insurance entity is not liable. If the member’s medical need is being considered, or should be considered, by a third party or insurance entity, the need is not shareable until Zion Health receives documentation to reflect a lack of liability or partial payment.
Cataract surgery is treated as a pre-existing condition and subject to the one-year waiting period before it is shareable. Each eye is considered a separate need and subject to an individual IUA.
Services related to the treatment of a specific musculoskeletal injury or disease are shareable for up to 25 office visits per need. All other chiropractic services will be treated as alternative medical practices and are subject to the limitations as outlined.
Chronic Pain Therapy
Services related to chronic pain therapy are treated as an alternative medical practice. They are shareable as part of a related eligible need, and members must get prior approval from Zion Health for the number and type of sessions. See the limitations on injections for more information.
Congenital conditions of children born outside a shareable maternity need will be considered pre-existing and subject to the waiting period for cost sharing.
Expenses related to cosmetic surgery are shareable only for disfiguration due to a shareable injury or illness.
Tooth damage caused by an accident or injury may be considered for sharing. Other dental services, such as caps, crowns, root canals, fillings, wisdom tooth extraction, and cleanings are not shareable.
Diabetic Medication & Supplies
Any medical expenses related to supplies, testing, medication, or other implements used to treat insulin-dependent diabetes are not shareable.
Emergency room visits are shareable for eligible medical needs related to an illness, injury, or accident. The first ER visit for a medical condition is treated as a normal need. 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.
Expenses related to fertility treatments are not shareable.
Needs resulting from a genetic mutation that existed prior to membership are subject to the same limitations as other pre-existing 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, needs related to the condition are considered shareable without pre-existing condition limitations.
Genetic testing will only be considered for sharing if it is required for the personal treatment of a shareable condition, such as breast cancer. Genetic screenings are not eligible for sharing.
Home healthcare expenses are shareable when related to an accident or injury and when the care has been prescribed by a licensed physician. Sharing of home healthcare expenses is limited to 30 days and/or $5,000.
Hospice care is shareable for 90-day periods when ordered by and under the care of a licensed care professional and upon physician approval or certification of terminal illness.
Hospitalization is shareable at a semi-private room rate. If a medical provider prescribes ICU or quarantine, those expenses are also shareable.
Inpatient or outpatient hyperbaric therapy may be shareable for the treatment of a specific illness or injury. Outpatient hyperbaric therapy is shareable for up to 35 therapy sessions.
Injections related to pain management for a shareable need are shareable up to $5,000. Hormone therapy injections related to a shareable need are shareable up to $3,000. Injections related to gender transitioning or sex reassignment therapy are not shareable.
Injuries Obtained From Certain Acts
Injuries or illnesses resulting from participation in a riot, criminal act, euthanasia, assisted suicide, or other such acts are not shareable.
International Medical Treatment
Medical expenses for emergency and acute care incurred outside the United States will be considered for sharing based on the Member Guidelines. Preventive or non-emergency services are not shareable without prior written approval from Zion Health.
Joint replacement surgery for degenerative or arthritic conditions is treated as a pre-existing condition and is subject to the waiting and phase-in periods.
Laboratory Tests And Checkups
Laboratory tests and checkups are shareable as part of an eligible need and prescribed by a licensed medical provider.
Long-Term Care And Skilled Nursing
Long-term care and skilled nursing are shareable when prescribed by a licensed medical provider for recovery from an injury or illness. Sharing for these services is limited to 90 days per medical need.
Medical equipment, including durable medical equipment (DME), is shareable if it is prescribed by a licensed medical provider and if it is related to a shareable need.
Failure or refusal to comply with a physician treatment plan and/or leaving a facility against medical advice (AMA) may result in ineligibility for sharing for the need and/or any complications that arise. The need will be subject to review and a determination made.
Medical supplies that directly aid in the treatment of, or recovery from, a shareable need are generally shareable 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 shared. Zion Health will share the retail costs (or fair costs when applicable) and, thus, encourages members to use alternative vendors such as local pharmacies or medical supply stores.
Medically Stable Conditions
A shareable need may be considered medically stable when the treating provider determines that the condition is chronic and further treatment will not likely result in improvement. At this point, the need is subject to review and may result in a determination of ineligibility for future sharing.
Expenses related to medications or other treatment for any mental health illness or condition is not shareable. Mental health conditions may include anxiety, depression, mental illnesses, and other psychological conditions.
Through LifeWorks, some Zion Health members may have access to sharing of regular, preventive mental health consultations. LifeWorks is available as an add-on to any membership.
Naturopathic care may be shareable pending written approval from Zion Health. Any expenses incurred prior to receiving written approval are not shareable.
Routine care for a newborn without complications is included with an eligible maternity need.
NICU care and other complications are treated as a separate need of the baby. Expenses related to circumcision are excluded from sharing. Expenses related to infant immunizations are shareable with the Direct Membership or Connected add-on to the Essential Membership as outlined in the Preventive Medical Sharing Guide.
Expenses related to nutritionist services are not shareable unless prescribed by a licensed medical provider. Zion Health must provide approval for nutritionist services prior to sharing.
Occupational therapy is shareable for inpatient treatment and up to 35 outpatient sessions per need, up to $7,500.
Organ transplants are shareable; however, they are subject to limitations for conditions existing prior to membership.
Physical therapy is shareable for inpatient treatment and up to 35 outpatient sessions per need, up to $7,500.
Prescriptions for medications related to an eligible need and that are billed by a provider are considered shareable.
Prescriptions filled at a pharmacy will be considered for sharing under the following conditions: prior approval is given by Zion Health, the prescription is related to the treatment of a shareable need, and prescription costs accumulate to $500 monthly. Sharing for these prescriptions is limited to 12 months.
Other prescription costs are generally not shareable. Members can receive prescription discounts through the Rx Share program. Many generic medications are available to members with Rx Share for $5 or $15 per month.
Preventive services are not subject to the IUA.
Annual office visits are shareable immediately upon membership activation, and may be used for preventive visits, specialist visits, or other services as outlined in the Preventive Medical Sharing Guide. Zion Health will share the member’s first qualifying submission; all other subsequent provider visits are the member’s responsibility until 12 months have passed since the qualifying visit.
Colonoscopies, mammograms, and youth immunizations (up to 18 years old) are shareable after six months of continuous membership. Well child checks are shareable as outlined in the
Preventive Medical Sharing Guide.
See the Preventive Medical Sharing Guide for more details.
Sleep apnea equipment and testing is not shareable with the Zion Health community.
Speech therapy in relation to an illness, injury, or accident is shareable 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 not shareable.
Medical expenses related to recreational sporting activities are generally shareable. 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 not shareable.
Elective sterilization, such as tubal ligation and vasectomy, is not shareable.
Suicide And Attempted Suicide
Zion Health encourages members to take advantage of our LifeWorks program as a mental health resource. However, we understand that in the event of a dependent suicide, financial assistance can slightly ease the burden on our members. For this reason, Zion Health will share in expenses related to the suicide or attempted suicide of an adolescent up to age 18, up to $25,000 and after a one-year waiting period of continuous membership.
Expenses related to a surrogate pregnancy, whether or not the surrogate is a member, are not shareable.
Therapeutic Massage Therapy
Expenses related to therapeutic massage are shareable if the therapy is related to an eligible need and prescribed by a licensed medical provider. Massage therapy is shareable for 25 sessions per need, up to $3,000.
Tobacco User Over 50
Medical cost sharing for the needs of tobacco users 50 years of age and older is limited to $50,000 for each of the following four disease categories:
• Heart conditions
• Chronic obstructive pulmonary disease (COPD)
Zion Health may share in vision-related expenses that are deemed medical.
Expenses related to weight reduction are shareable if prescribed by a licensed medical provider and approved by Zion Health—up to $3,000 per need.