ShareRight - Sharing Overview

Sharing Overview

Annual Sharing Limit

Each member's annual sharing cap is set at $500,000 per membership year.

CO-SHARE ARRANGEMENTS

As a ShareRight member, once your PRA requirement has been fulfilled, you contribute 10% towards all Eligible Medical Bills as part of a co-share arrangement. The remaining 90% is distributed for sharing among the Share Right membership.

Additionally, there is a co-share limit of $5,000 per household per year. Essentially, once the member has paid a total of $5,000 in co-shares, they will not be required to contribute further until the amount resets on their Membership Date.

CO-SHARE MAXIMUM The household is subject to a co-share limit of $5,000 per membership year.

Limitation During Initial 60 Days of Membership

Initial 60-Day Membership Provision:

During the first 60 days of membership, members can have up to $50,000 of their Eligible Medical Bills shared (excluding pre-existing conditions).

This provision does not extend to newborns added within 30 days of birth. Additionally, maternity sharing is capped at $150,000 per single pregnancy event per year. There is no lifetime limit on sharing.

Lifetime Sharing Caps for Smokers

Medical cost sharing for tobacco users aged 50 and older is restricted to $50,000 lifetime for each of the following four disease categories:

Stroke
Cancer
Heart Conditions
Chronic Obstructive Pulmonary Disease (COPD)

The tobacco assessment does not apply to seniors.

Submission of Member Bills

Member Bill Submission Procedure:

If a member needs to submit a bill for processing, it must be done electronically using the Medical Expense Form (MEF) at

When completing a Medical Expense Form (MEF), members must ensure they have obtained all necessary information for processing. Only MEFs containing all required information will be accepted for processing.

Outpatient Mental Health Services

Specialist Provider Fee: $75

Co-Share: 10% once PRA has been met

Eligibility for Sharing: Services must be performed by a qualified provider, up to 5 visits per member per membership year.

Note: Outpatient Mental Health providers are categorized as Specialists for provider fee purposes and are subject to the PRA and co-share.

PRE-EXISTING MEDICAL CONDITIONS

Pre-Existing Medical Conditions are characterized by signs, symptoms, testing, diagnosis, treatment, or medication usage within 36 months before membership (as per medical records.)

A known sign denotes any abnormality suggestive of disease identified during examination or diagnostic testing before joining the membership. Symptoms refer to subjective indications of disease, while signs are objective.

For instance, if you were diagnosed with cancer in complete remission and are undergoing surveillance testing, related bills won't be eligible for sharing within the initial 36 months of membership.

Following this period, if you remain without signs, symptoms, testing (apart from surveillance), diagnosis, or medication treatment, medical expenses associated with the cancer diagnosis become eligible for sharing.

Pre-elgibilty review

A pre-eligibility review is required for any of the following treatments to be eligible for sharing:

• Cancer Treatment

• Elective Cardiac Procedures

• Non-emergency inpatient/outpatient surgery

• Organ/Tissue Transplant Services

• Maternity

• Imaging: MRIs and Nuclear Imaging (i.e. PET scans)

3-5 business day notice required, expedited review on a case-by-case basis. Medical records are required to determine pre-eligibility and failure to provide requested records for review will result in the bill being ineligible for sharing.

Providers may request pre-eligibility by calling (855) 378-6777 or online.

Prescription Medications

Show Your Member Card at the Pharmacy.

Prescription medications are eligible for sharing when unrelated to a pre-existing condition and:

After the first $25 for generics.
After the first $50 for brand-name medications when generics are unavailable.
Medications must be purchased using the member ID.
Members cover 100% of the cost upfront at the pharmacy.
Psychotropic medications and birth control are not eligible for sharing.
The maximum sharing amount for prescriptions is $1200 per member per membership year after the PRA has been met."

Primary Responsibility Amount (PRA)

$2,500
$5,000
$7,500
$10,000
**$1,000 for ShareRight Members aged 65 and above

The Primary Responsibility Amount (PRA) represents the sum a Household must contribute towards their own Eligible Medical Bills within a 12-month period before the sharing by the membership commences.

All Eligible Medical Bills are subject to the annual PRA and co-share, except for the annual/well office visit and lab allowance outlined in section III. D.

The PRA 12-month period commences on the Membership Date and resets on the anniversary of your Membership Date. Your Membership Date corresponds to the commencement date of your membership in the ShareRight Sharing Plan. Members have the option to modify their PRA amount on the anniversary of their Membership Date.

Healthcare Provider Fees

When accessing medical services, members incur the following charges:

$0 for Telemedicine via Member Portal only
$50 for Primary Care
$50 for each Allergy Test/Serum Injection
$75 for Specialist/Urgent Care and Outpatient Surgical Facilities
$150 for Emergency Room or Inpatient Hospitalization

These fees are separate from the PRA and are applicable even if the member has already met their PRA for the year.

Online Mental Health Services

Virtual Mental Health Care, provided by an approved teletherapy provider endorsed by ShareRight, qualifies for sharing. Members are required to cover the full session consultation fee at the time of service and can later submit appropriate receipts to ShareRight for processing using the Medical Expense Form.

Virtual Mental Health Care falls under the category of Specialists for provider fee purposes and is subject to the PRA and co-share.

Wellness Visits and Screening Tests - Ages 6 and Below

For ShareRight Members Under Age 6, one annual visit is provided. Additional visits adhere to routine well-child guidelines outlined by the American Academy of Pediatrics. These visits are subject to the PRA and co-share. Well-child care encompasses recommended routine check-ups and associated lab work, excluding vaccinations or immunizations.

Wellness Visits and Screening Tests – Age 6 and older

Annual Wellness Visits and Diagnostic Tests Eligible for Sharing:

Both the annual/well office visit and $150 lab allowance are fully shareable and exempt from the PRA or co-share.

• One annual/well office visit for members aged 6 years and older per membership year. This includes a $150 allowance applicable to any of the listed labs below:

Complete Blood Count with Differential and Platelets
Comprehensive Metabolic Panel
Lipid Profile with Lipoprotein Particle Assessment
Hemoglobin A1C
Vitamin D-25 OH
C-Reactive Protein
Fecal Occult Blood Test
Pap Smear
PSA

SHARING SPECIFICS

ABORTION

Not eligible for sharing.

Acupuncture Not eligible for sharing.

Allergy injections, serum and testing

$50 for each Allergy Test/Serum Injection

These fees are not applied to the PRA and are paid even if the member has met the PRA for the year. For eligible services, the Provider Fee is applied, then any remaining PRA and finally the Co-share is applied up to the Co-share limit.

Alternative treatment Not eligible for sharing.

Ambulance (ground transfer) Medical transportation to the nearest facility, including ground and air ambulance services to hospitals, is eligible in emergency situations or when medically necessary for transport for admission to another medical facility.

Air ambulance

Subjected to 10% co-share once PRA has been met.

Medical transportation to the nearest facility is eligible in emergency situations or when medically necessary for admission to another medical facility.

Air ambulance is limited to $25,000 lifetime max per member.

Ambulatory/Outpatient Surgical Center Expenses

Subjected to 10% co-share once PRA has been met.

Anesthesia Expenses Subjected to 10% co-share once PRA has been met.

Assistant Surgeon/Surgeon Expense Subjected to 10% co-share once PRA has been met.

Biofeedback Not eligible for sharing.

Chemotherapy/Radiation Expenses

Subjected to 10% co-share once PRA has been met.

Pre-notification required.

Colonoscopy - Diagnostic and Routine

Subjected to 10% co-share once PRA has been met.

Routine Colonoscopy 1 every 10 years starting at age 45 or one every 5 years for members at high risk.

Dental/Injury Trauma Not eligible for sharing, unless related to an eligible medical injury or illness.

Durable Medical Equipment

DME related to an eligible need is eligible for sharing for up to $500 per member per membership year toward the rental or purchase once the PRA has been met.

DME expenses are also subjected to PRA and co-share.

Emergency Room Visit $150 provider fee. Subjected to 10% co-share once PRA has been met.

Experimental Treatment Not eligible for sharing.

Fertility/Infertility Not eligible for sharing.

Genetic defects, hereditary disease, or congenital conditions

Treatment related to genetic defects, hereditary diseases, or congenital conditions present before membership is not eligible for sharing.

Fetal abnormalities and/or congenital abnormalities noted in medical records prior to the mother joining Impact Health Sharing, will be considered a pre-existing condition and would not be eligible for sharing.

Genetic Testing Genetic testing is only shareable for an existing medical condition (that is not a pre-existing condition). Routine genetic testing is not eligible for sharing.

Hearing Aides Not eligible for sharing.

Home HealthCare

Skilled care at home services for an eligible need are limited to 40 visits per member per membership year by a registered ARNP, LPN, or RN. A visit is limited to a maximum block of 4 hours.

Subjected to 10% co-share once PRA has been met.

Hospice Care

Hospice care services are eligible for sharing
when prescribed by a physician and is subject to a lifetime limit of $15,000 per member once PRA has been met and subject to co-share.

Inpatient Hospital Expenses

$150 provider fee.

Subjected to 10% co-share once PRA has been met.

Inpatient Mental Health/Substance Abuse Not eligible for sharing.

Lab, X-ray, diagnostic imaging

Subjected to 10% co-share once PRA has been met.

Diagnostic tests are eligible for sharing as follows: (Both the annual/well office visit and $150 lab allowance are 100% sharable and not subject to the PRA or co-share.) See III.D

Maternity

Subjected to 10% co-share once PRA has been met.

Eligible if mother has been a member for 12 months.
Sharing is limited to $150,000 per single pregnancy event (not including baby’s bills).

Newborns

Can be added to the membership at birth and must be done within 30 days.

Mammogram - Diagnostic and Routine

Subjected to 10% co-share once PRA has been met.

Routine mammogram 1 every year for ages 45-54 and one every 2 years for ages 55 and over

Medical Marijuana Not eligible for sharing.

Motorcycle Accidents

Treatment is limited to $100,000
per incident once PRA has been met, subject to co-share. Sharing will be secondary to the vehicle insurance.

Treatment will not be shared if there is abuse of alcohol or legal drugs or the use of federally illegal drugs.

Naturopathic Treatment Not eligible for sharing.

Non-prescription drugs and medical supplies Not eligible for sharing.

Orthotics Not eligible for sharing.

Prostheses

Prostheses are eligible for sharing, up to two max per lifetime for the same condition once PRA is met, is also subject to co-share.

*Limited Sharing is subject to the PRA and co-share

Skilled Nursing Facility Not eligible for sharing.

Sleep Studies

Subjected to 10% co-share once PRA has been met.

Only if related to a specific disease or disorder.

Specialist

Subjected to 10% co-share once PRA has been met.

$75 provider fee.

Substance Abuse Not eligible for sharing.

Temporomandibular Joint Disorder (TMJ) Subjected to 10% co-share once PRA has been met.

Therapy : Chiropractic Adjustment • Physical Therapy • Occupational Therapy• Speech Therapy• Cardiac Rehabilitation• Vision Therapy

Outpatient therapy is limited to 50 visits per member per membership year regardless of the type of outpatient therapy, provided it is included in the list below and (subject to PRA and co-share)
• Chiropractic Adjustment
• Physical Therapy
• Vision Therapy
• Occupational Therapy
• Speech Therapy
• Respiratory Therapy
• Cardiac Rehabilitation

Urgent Care

$75 provider fee +

Subjected to 10% co-share once PRA has been met.

Vaccinations/ Immunizations Not eligible for sharing.

Vision

Routine vision not eligible for sharing.

Medical conditions such as Glaucoma or Cataracts and services related to a medical injury or illness are sharable.

Weight Management Treatment or Procedure Not eligible for sharing.