Comprehensive Member Guidelines
About ShareNet
ShareNet Ministries is a not-for-profit healthcare sharing ministry that facilitates member-to-member cost-sharing. ShareNet is NOT insurance, and these Guidelines are not a contract for insurance, nor do they constitute a legally binding contract in any way. The Guidelines provide a general overview of how membership works, as well as more specific descriptions of what is eligible for sharing among members. ShareNet maintains and reserves the right to exclude sharing of needs for pre-existing conditions, whether disclosed at the time of enrollment or not.
As a condition of Membership in ShareNet I affirm the following shared beliefs:
- I believe that the first and greatest command is to “love God with all my soul and with all my mind” (Deuteronomy 6:4–5, Matthew 22:37, Luke 10:27).
- I believe that the second greatest command is to “love my neighbor as myself” (Leviticus 19:18, Mathew 22:38 Luke 10:27)
- I believe that the teachings of Luke 10: 27 – 37 instructs me to “love my neighbor” regardless of race, religion, or creed.
- I believe that I am instructed to share my neighbor’s burdens in Galatians 6:2: “Carry each other’s burdens, and in this way, you will fulfill the law of Christ”;
- I believe that the voluntary sharing of medical expenses by members under ShareNet’s guidelines—which I understand is not insurance—exemplifies the precept outlined in Luke 10:8-9 that “[w]hatever city you enter, and they receive you, eat such things as are set before you. And heal the sick there, and say to them, ‘[t]he kingdom of God has come to you”;
- I believe ShareNet members have the right to direct their own health care, free from government dictates, restraints, or oversight, and I want to be part of a health share community whose mission is to assist members through their personal health care challenges through voluntary sharing of expenses.
- I believe that the United States Constitution guarantees my fundamental right to associate in the lawful exercise and expression of my faith through the sharing of healthcare expenses with my neighbors.
- This Statement of Shared Beliefs does not exhaust the extent of my faith and beliefs. My beliefs and the expression of my faith is inspired by the Bible, the word of God, and speaks final authority concerning truth and the proper conduct of mankind.
ShareNet Program Details
ShareNet is a not-for-profit healthcare sharing ministry that facilitates member-to-member cost-sharing.
The Program is designed for sharing medical expenses related to conditions resulting from a new illness, injury, or accident.
To participate, members voluntarily contribute a monthly share amount according to the age of the oldest member in the household, the sharing level you choose, and the number of participants in your membership.
The Annual Unshared Amount is the dollar amount a household must pay toward their own Eligible Medical Bills during a 12-month period. Eligible Medical Bills in excess of the AUA may be published and shared by the membership.
The AUA 12-month period begins on the Membership Date/Effective Date.
The AUA resets on the anniversary of your Membership Date/Effective Date. Your Membership Date is the date that your membership in the ShareNet Program started.
The Effective date is the date the member’s current AUA has begun. This Date may be different from the Membership Date if a Member has switched some elements of their membership.
A member may only increase their selected AUA one time during their first year of membership. After the first year of membership, members may decrease (or increase) their selected AUA, but only on their anniversary date unless they experience one of the following qualified Events:
- Change in legal marital status – marriage, divorce, annulment, death of a spouse, or legal separation.
- Change in dependent children – birth, adoption, legal guardianship, or death of a child.
- Loss of spousal coverage due to loss of job.
- Dependent children “age out” – the child’s age exceeds the age limitations of the membership.
At the time of receiving service from a medical care provider, members pay the following to the provider:
- $0 for virtual visits with ShareNet’s telemedicine partner (accessed through the ShareNet Member Center).
- $20 for Primary Care.
- $ 50 for Specialists.
- $ 75 for Urgent Care and outpatient treatment.
- $150 for Emergency Room or Inpatient Hospitalization.
- $75 for Diagnostic Testing & Imaging (EKG, X-ray, CT scan, MRI, ultrasound, mammogram, etc).
- $3,000 for Maternity
These fees are not applied to the AUA and are paid even if the member has met the AUA for the year. For eligible services, the Provider Fee is applied, then the remaining AUA.
These Guidelines explain the program requirements and govern the sharing of medical bills. The Guidelines in effect at the time of service govern the program, not the Guidelines in effect when a member joined or changed after the time of service. The Guidelines are available online at www.sharenetnow.org and in your Member Center.
Changes to the Guidelines can be made at any time by a majority vote of the ShareNet board of directors. Members will be notified of the changes and a history of changes will be available in the ShareNet Member Center for 2 years from the date of the change.
ShareNet is not insurance. ShareNet is a Healthcare Sharing Ministry as outlined in the Patient Protection and Affordable Care Act and was created to facilitate the sharing of medical bills and expenses among members, one with another, according to these Guidelines, at ShareNet’s reasonable discretion. ShareNet is not liable for the payment of a member’s medical bill. If sharing occurs, the shared medical bills are paid by the member that incurred the bill from other members’ share contributions only, not from funds of ShareNet itself.
SHARENET IS NOT AN INSURANCE COMPANY. HEALTHCARE SHARING IS NOT INSURANCE OR A CONTRACT FOR INSURANCE. THE PAYMENT OF MEDICAL BILLS BY MEMBERS THROUGH SHARENET OR OTHERWISE IS NOT GUARANTEED IN ANY WAY.
There is no transfer of risk from a member to ShareNet or from a member to other members; and there is not a contract of indemnity between ShareNet and any member or between the members themselves.
Membership
To be eligible to participate in ShareNet an applicant must:
- Agree with the Statement of Beliefs.
- Abstain from the use of illegal drugs for at least twelve months prior to applying for membership.
Members must not use illegal drugs.
An adult child (18-25) needs to meet the same requirements in order to be on his or her parent(s) household membership and to have their bills shared.
Medical information is provided during the application process. IF AN APPLICANT OR MEMBER FAILS TO DISCLOSE MEDICAL HISTORY OR LIFESTYLE HABITS OR CHOICES THAT MAY DISQUALIFY THEM FROM MEMBERSHIP AND THAT INFORMATION IS DISCOVERED, MEDICAL BILLS MAY NOT BE SHARED, AND/OR MEMBERSHIP MAY BE CANCELLED.
Participation in ShareNet will be an online process, and monthly share contributions must be made using Electronic Funds Transfers (EFTs) or other acceptable payment forms as determined by ShareNet. The EFT contributions will electronically transfer from the member’s bank account to a sharing account held at a participating bank that has partnered with ShareNet in order to send funds to other members. Receiving members will receive those funds in bill account(s), the sole purpose of which will be to pay eligible bills. ShareNet will then direct the payment of those funds either to the appropriate medical provider or to the member in the case of reimbursement.
Body Mass Index (BMI) Assessment
Since obesity has been shown to cause many health issues, ShareNet encourages members and applicants to have a healthy Body Mass Index (BMI). BMI Assessment criteria (based on weight and height) have been established by ShareNet, which may require applicants to pay an additional monthly amount. To remove this additional amount, members must provide documentation that shows they have lowered their BMI below the set criteria. You will be notified during the application process before you join if you qualify for this additional amount of $125 per month. The BMI fee will not be charged to more than one member per household, but to remove it, all members must meet the set criteria.
Tobacco Use Assessment
The use of tobacco has been shown to not only cause disease but to also impede the body’s healing processes. Therefore, ShareNet encourages applicants and members not to use tobacco or vaping products. Members who use tobacco or vaping products are required to pay a Tobacco Assessment of $75 per month. This tobacco/vaping fee will not be charged to more than one member per household, but to remove it, all members must meet the criteria.
Members who do not disclose this information may be subject to membership cancellation if it is determined after the membership date.
You will be notified during the application process before you join if you qualify for this additional assessment.
You, your spouse, and your dependent children can be included in your membership.
SPOUSE
Spouse means a legally married person. It can be a person’s lawfully married husband or wife. Marriage is defined as being between one biologically-born man and one biologically-born woman.
DEPENDENT CHILD(REN)
If you are legally and financially responsible for the child(ren), they can be added to your membership.
ADOPTED CHILDREN
When a ShareNet member adopts a child or otherwise has obtained legal custody with legal responsibility for a child’s medical care, that child can be included in your ShareNet membership. If any other source is responsible, willing, or available to pay the child’s medical bills, these resources must be exhausted before ShareNet members can share those bills. Medical bills for the birth of an adopted child are not eligible for sharing, regardless of the circumstances.
ADOPTED DISABLED CHILDREN
In cases when members choose to adopt a child(ren) with known disabilities, there are other resources and programs designed to assist and provide for adopted, disabled children. It is the responsibility of the adoptive parent(s) to research what resources are available and to obtain the necessary funding. ShareNet considers these needs to be pre-existing (see section xxxx “Pre-existing Conditions”).
ADULT CHILDREN
Adult children can remain on their parents’ membership until their 26th birthday as long as they meet the following qualifications:
- They must share the core values of ShareNet members and attest to the Statement of Beliefs; and
- They must be single; and
- They must be legal dependents. Legal dependents are defined as children who are reported as dependents on their parent’s income tax forms.
Children who are no longer legal dependents can transition seamlessly to their own ShareNet membership. The immediate transition will allow any issues relating to pre-existing conditions to date back to the original start date when they participated under their parents’ membership.
ShareNet memberships will be automatically terminated on the last day of the month in which the member turns 65 years old.
The following individual(s) can join ShareNet.
- Those who possess a U.S.-issued Social Security Number and a valid Identification Card issued by a U.S. government agency.
- Those who possess a U.S.-issued Individual Taxpayer Identification Number (ITIN) and who also have a government-issued identification card issued by Mexico, Canada, Guatemala, or the United States and who have a United States mailing address.
Membership will be canceled if members do not deposit their monthly share for more than sixty (60) days past the due date. The cancellation date will be the last day of the month for which the last monthly share was deposited. Only eligible medical bills incurred on or before the cancellation date will be considered eligible for sharing.
Bill Sharing
For the first 60 days of membership, members are eligible to have up to $50,000 of their Eligible Medical Bills shared after their AUA has been met (excluding pre-existing conditions). This limitation does not apply to newborns added within 30 days of birth.
Maternity sharing is limited to $150,000 for mother and $100,000 for baby/babies per pregnancy event. There is an additional Provider Fee of $3,000 applied to mother’s bills at time of delivery.
There is an additional AUA of $3,000 applied during the membership year that contains the baby’s birth date.
There is an annual sharing cap of $500,000 per member per Membership Year. If desired, applicants or members can choose a $1,000,000 annual sharing cap during the application or on their anniversary date for a higher monthly share amount. If selected, the cap cannot be reduced back to $500,000.
There is no lifetime limit on sharing unless otherwise specified herein, e.g., prosthetics and hospice care.
Members who are tobacco/vaping users will have a combined shareable limit of $25,000 per membership year for the following medical conditions: Cancer, Heart Conditions, COPD, and Stroke.
For additional Sharing limits not listed above, see section D. Limited Sharing.
ShareNet utilizes multiple sources and approaches to discount members’ medical bills to a reasonable amount, as is standard in healthcare today. Eligible medical bills are shared at the discounted rate less any AUA and/or Provider Fee.
The maximum shareable amount for a preventative mammogram is $150. This is not eligible for sharing in the first six months of membership.
The maximum shareable amount for a preventative colonoscopy is $1500. This is not eligible for sharing in the first six months of membership.
To be eligible for sharing, testing and treatment must be CMS- or FDA-approved and submitted on a CMS 1500 form or a UB and IB form, and ordered by a:
- Medical Doctor (M.D.)
- Doctor of Osteopathy (D.O.)
- Nurse Practitioner (N.P. or A.P.R.N.)
- Physician’s Assistant (P.A.)
- Doctor of Podiatric Medicine (D.P.M.)
- Dentist (D.D.S. or D.M.D.)
- Midwife
- Ophthalmologist
These CMS- or FDA-approved tests and treatments must occur at one of the following:
- Hospital
- Surgery Center
- Clinic
- Doctor’s office
- Diagnostic facility
Diagnosis and treatment are to be performed in the U.S. to be eligible for sharing, except in emergencies while traveling.
Medical bills related to a new condition, injury, or illness are eligible for sharing, provided they are not listed in Section III. E. “Not Eligible for Sharing.” These bills may be subject to limitations if they are listed in Section II. D. “Limited Sharing.” Eligibility for sharing cannot be fully determined until after medical services are received, and bills are submitted for sharing.
Bills for active members must be received by ShareNet within 12 months from the date of service to be considered for sharing.
Most medical providers are willing to submit their bills electronically directly to ShareNet’s processor. However, in the event that a member must submit a bill for processing and/or reimbursement, it must be submitted through the online member portal.
When submitting a medical bill for processing, members are responsible for obtaining all information needed for processing per the form available online.
1. Pre-existing conditions
Pre-existing medical conditions are conditions in which signs, symptoms, testing, treatment, or use of medication occurred within 24 months prior to membership start. Routine or maintenance medications are considered treatment.
Pre-Existing Conditions are eligible for sharing after the 24th month of continuous membership.
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2. Maternity
Maternity is eligible for sharing if the mother’s expected due date is at least twelve months after joining ShareNet. Sharing is limited to $150,000 for mother (including antepartum care, the cost of delivery, any complications to the mother, and postpartum care) and $100,000 for baby or babies for any single pregnancy event (regardless of how many babies are born during the event).
If the mother’s expected due date is at least twelve months after joining ShareNet, medical bills for congenital conditions are eligible for sharing as part of the baby’s medical bills if the child is added as a member within 30 days of birth. After initial discharge, any medical bills related to a congenital condition in the child which first produces symptoms and is first discovered after birth will not be considered a pre-existing condition if the child is added as a member within 30 days of birth.
For ineligible maternity events, any fetal abnormalities and/ or congenital abnormalities noted in medical records prior to the mother joining ShareNet, will be considered a pre- existing condition and would not be eligible for sharing.
For delivery charges to be eligible, delivery must be performed by a Medical Doctor, Doctor of Osteopathy, or Midwife who is properly licensed, certified, and/or registered in the state of delivery.
The newborn can be a member from birth if a request to add them to the membership is made within 30 days of the date of birth.
If the mother is not a member for twelve months prior the expected due date, the following are instances where maternity bills are ineligible for sharing:
- Medical bills incurred before the newborn’s membership date.
- Unresolved maternity medical conditions of child or mother.
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3. Prescription Medications
Prescription medication expenses for prescribed drugs that may be dispensed, injected, or administered are eligible for sharing and may be credited toward the AUA if they are not considered a treatment for chronic conditions that were pre-existing when the member joined ShareNet. The prescription amount in excess of the two thresholds below will be applied to the member’s AUA if it has not been met. If the AUA has been met, then the excess prescription amount is eligible for sharing as a reimbursement to the member up to $2,000 per member per year:
- After the first $15 on a generic drug prescription (up to 30 days’ supply) or $45 for a 90 days supply.
- After the first $65 on brand name prescription when a generic is unavailable (up to 30 days’ supply) or $195 for a 90 days’ supply.
- Prescription medications must be purchased using the member ID card (see Rx information on the card).
- Members can search for and find the best Rx pricing on the ShareNet website.
- Members pay 100% of the prescription amount at the local pharmacy.
- Prescription drugs that may be dispensed, injected, or administered.
- Psychotropic medication and birth control expenses are not eligible for sharing.
- For prescription drugs over $150, members must first utilize the SHARx program (see ShareNet Member Center).
Exceptions may be made in the case of medication for cancer and transplant recipients.
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4. Well-Child Care
Infants and Children: Sharing for routine well-childcare is eligible until the child reaches the age of six. Well- child care is defined as recommended routine check-ups and associated lab work, excluding vaccinations and/or immunizations. (see section E. Not Eligible for Sharing) If the AUA has not been met, these visits will be applied first to the AUA; any remainder is then eligible for sharing.
5. Screenings
Women: Mammogram—one every year for ages 45-54 then every two years starting at age 55. After the provider fee has been paid, this will be shareable even if the AUA has not been met. Mammograms are not eligible for sharing in the first six months of membership.
Women: Pap test—one every three years from age 21-65. If the AUA has not been met, this will be applied first to the AUA; any remainder is then eligible for sharing.
Men: PSA test—one every year, starting at age 45. If the AUA has not been met, this will be applied first to the AUA; any remainder is then eligible for sharing.
All: Colonoscopy—one every 10 years starting at age 45 or one every five years for members at high risk according to their physician. If the AUA has not been met, this will be applied first to the AUA; any remainder is then eligible for sharing . A colonoscopy is not eligible for sharing in the first six months of membership.
As it pertains to eligible preventive care for both men and women, after the Provider fee has been paid, both the test and coordinated office visit will be applied first to the AUA: any remainder is then eligible for sharing unless otherwise specified.
No labs or ancillary services will be eligible if included in this visit.
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6. Mental Health Care
Outpatient Mental Health Care is eligible for sharing if performed by a qualified provider. Virtual Mental Health Care (online) is eligible for sharing through ShareNet’s teletherapy provider via the Member Center. Mental Health providers are considered a Specialist for Provider Fee purposes. Up to 6 visits (a combination of Outpatient and Virtual) per member per membership year are eligible for sharing.
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7. Therapies
Medical bills for outpatient Vision Therapy, Cardiac Therapy, Respiratory Therapy, Physical Therapy, Occupational Therapy, Speech Therapy, and/or are Chiropractic adjustments are shareable up to a combined maximum of 55 visits per member per membership year when necessary to reverse, control, or recover from an injury or medical condition. Sharing is subject to pre-existing condition restrictions.
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8. Durable Medical Equiptment
Durable Medical Equipment (DME) is eligible for sharing if it is ordered by a qualified CMS-approved provider and is related to an eligible illness or injury. DME is eligible for sharing up to $500 per member per membership year toward rental or purchase. Motorized wheelchairs, motorized scooters, exercise equipment, breast pumps and home modifications are not eligible for sharing.
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9. Prosthetics
Prosthetics are eligible for sharing if the underlying medical condition or injury was eligible for sharing. Prosthetics are limited to a lifetime cap of $5,000 per member.
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10. Motor Vehicle Accidents
Motor Vehicle Accidents- Medical bills incurred from the use of motorized vehicles will only be shareable for any amount remaining after an insurance entity or other liable third party has paid first if all other Guideline requirements have been met. In addition, medical bills related to the motorized vehicle accident will not be eligible for sharing if any of the following applies:
- The operator of the vehicle was impaired by the use of alcohol or any illegal substances in accordance with the law.
- The vehicle was used in to race another vehicle, to perform a stunt, or in the commission of a crime.
- The operator’s age was below that required by law, or the operator was not legally licensed as required by law.
There are many variations in auto insurance policies and numerous state rules and regulations regarding auto insurance. Therefore, ShareNet has not set a minimum requirement for members regarding auto insurance. However, for the sake of keeping monthly financial contributions low, we strongly urge you to set the highest possible limit on the medical assistance available through your auto insurance policy.
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11. Tobacco Usage
Members who are tobacco/vaping users will have a maximum shareable limit of $25,000 for the following medical conditions: Cancer, Heart Conditions, COPD, and Stroke.
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12. Medical transportation
Medical transportation (ground), is eligible for sharing in emergency situations or when medically necessary for transport for admission to another medical facility. Ground transportation is limited to $500 per incident. Medical bills for emergency flights and/or transportation to the United States, are not eligible for sharing even if the situation is life-threatening. We strongly encourage you to look into other available resources. In the case of international travel, travel medical insurance can typically be purchased through a travel agent. There are also programs available for a monthly fee in case you ever need to be air-lifted.
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13. Home Health Care
Skilled care at-home services for an eligible need are limited to 20 visits per member per membership year by a registered ARNP, LPN, or RN. A visit is limited to a maximum block of 4 hours.
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14. Hospice Care
Hospice care services are eligible for sharing when prescribed by a physician and are subject to a lifetime limit of $15,000 per member.
Dental expenses unless for the repair of broken teeth due to an accident that occurred while the ShareNet member was in good standing and the accident was not caused by chewing.
Vaccinations and/or immunizations
Expenses from Temporomandibular Joint Disorders (TMJ/TMD) are not eligible for sharing. This exclusion applies regardless of variations in diagnostic coding (i.e., micrognathia, congenital malformations of the jaw, etc.), where treatment is being rendered, or the type of practitioner providing the treatment.
Bills for sleep apnea diagnosis and treatment or equipment prescribed, administered, or recommended by a dentist are not eligible for sharing.
Vision correction including optometrist services, eye exams, eyeglasses and contact lenses.
Audiological expenses including hearing aids.
Over the counter medications, vitamins and nutritional supplements.
Elective, non-health related cosmetic surgery and any complications arising from such procedures. Exception: Bills from medically necessary breast reductions are eligible for sharing.
Weight reduction programs or procedures.
Abortions.
Infertility testing or treatment; sterilization or reversal.
Gestation or surrogate maternity procedures; in vitro fertilization and associated maternity bills (see Guideline R.5).
Genetic testing is ineligible unless required for determining treatment for a current medical condition. Medical records must be provided.
Inpatient psychological treatment, tests, or counseling, however, emergency room bills and subsequent hospitalization that are incurred to physically stabilize the patient are eligible for sharing and are limited to three (3) days per member per membership year.
Bills incurred as the result of the abuse of drugs or alcohol, including charges for residential treatment centers.
Charges for treatment of any intentionally self-inflicted illness or injury, including suicide or attempted suicide.
Medical supplies including, but not limited to, syringes, test strips, lancets, orthotics, batteries, etc.
Alternative treatment including, but not limited to, acupuncture, experimental or investigational treatments,including blood work or testing supporting alternative treatment. This exclusion applies regardless of the type of practitioner (naturopathic, homeopathic, medical doctors, etc.)
Prescription Vitamins/Supplements without a diagnosis of a specific deficiency.
Expenses related to the donation/harvest of an organ unless both the donor and recipient are members of ShareNet.
Non-medical expenses such as travel expenses, postage, shipping, finance charges, interest, nutritionist services, phone calls, private room upcharge, etc.
Nursing home care and/or rehabilitative housing.
Any therapy performed for developmental or educational reasons.
Health or medical practice membership fees or gym membership fees.
Charges for services, supplies, or treatment from
any hospital owned or operated by the United States government or any agency thereof or any government outside the United States, or charges for services, treatment, or supplies furnished by the United States government or any agency thereof or any government outside the United States, unless payment is legally required.
Charges for an injury sustained or illness contracted while on active duty in military service unless payment is legally required.
Charges for services, supplies, or treatment for treatment of illness or injury which is caused by or attributed to by war or any act of war (whether declared or undeclared, civil or international, or any substantial armed conflict between organized forces of a military nature), or participation in a riot, civil disobedience or insurrection.
Charges in connection with any illness or injury arising out of or in the course of any employment intended for wage or profit, including self-employment. This is typically covered under the member’s worker’s compensation insurance.
Charges in connection with any illness or injury sustained while taking part or attempting to take part in an illegal act, including but not limited to misdemeanors and felonies, or for any injury or illness that arises from or is caused during the commission of any illegal act. It is not necessary that an arrest occur, criminal charges are filed, or, if filed, that a conviction result for the Administrator to determine that an act constitutes an illegal act. Proof beyond a reasonable doubt is not required to be deemed an illegal act. The Administrator has the sole discretion to determine whether a particular act constitutes an Illegal Act.
Any charge in connection with any Illness or Injury that results from engaging in a hazardous pursuit, hobby, or extreme activity without using the recommended safety equipment. A pursuit, hobby, or activity is hazardous if it involves or exposes an individual to risk of a degree or nature not customarily undertaken in the course of the member’s customary occupation or if it involves leisure time activities considered by the Administrator, taking all circumstances into account, as involving unusual or exceptional risks, characterized by a threat of danger or risk of bodily harm.
To the extent that sharing under this ShareNet membership is prohibited by any law of the jurisdiction in which the member resides at the time the expense is incurred.
Any services, supplies, or treatment for which the member is not legally required to pay; or for which no charge would usually be made; or for which such charge, if made, would not usually be collected if no sharing allowances existed; or to the extent, the charge for the care exceeds the charge that would have been made and collected if no sharing allowances existed.
Charges incurred outside the United States if the Member traveled to such a location for the sole purpose of obtaining services, supplies, or treatment.
Charges for services, supplies, or treatment rendered by any individual who is a close relative, as determined by the Administrator, of the member or who resides in the same household as the member.
Charges for services, supplies, or treatment rendered by facilities, physicians, or professional providers beyond the scope of their license; for any treatment, confinement, or service which is not recommended by or performed by an appropriate professional provider.
Charges for illnesses or injuries sustained by a member due to the action or inaction of any party if the Mmmber fails to provide any information as specified in the Subrogation section or as requested by ShareNet in connection with any third-party recovery.
Needs not submitted within the timely filing limit deadlines as specified.
Expenses which are shareable under any one section of the Member Guidelines shall not be shareable under any other section of the Guidelines.
Charges for services, treatment, or care of any kind that are provided due to a court order or are required by a court of law and/or are imposed as an alternative to, or in addition to, fine or imprisonment. This exclusion shall not apply to expenses for the illness or injury that would be shareable under the membership in the absence of a court order and for which the member is legally obligated to pay.
Charges for administrative fees; completion, filing, or copying of Need forms, itemized bills, or medical reports; reports or appearances in legal proceedings, mailing, postage, or shipping and handling; missed appointments; late fees; sales tax; interest or penalties; travel time or expenses; or telephone consultations.
Charges for the release and review of medical records.
Charges for services, supplies, or treatment for transsexualism, gender dysphoria, or sexual reassignment or change, including medications, implants, hormone therapy, surgery, and medical or psychiatric treatment. Charges for treatment or surgery for sexual dysfunction.
Charges for biofeedback therapy.
Charges for services, supplies, or treatments provided by your Employer.
Charges for services, supplies, or treatments provided by an educational institution as required by law.
Except as medically necessary for the treatment of metabolic or peripheral-vascular illness, charges for routine, palliative, or cosmetic foot care, including, but not limited to; treatment of weak, unstable, flat, strained, or unbalanced feet; subluxations of the foot; treatment of corns or calluses; non-surgical care of toenails.
Charges for custodial care, domiciliary care, or rest cures.
Charges for travel or accommodations.
Charges for professional services billed by a physician or Registered Nurse, Licensed Practical Nurse, or Licensed Vocational Nurse who is an employee of a hospital or any other facility and who is paid by the hospital or other facility for the service provided.
Charges for environmental change, including hospitalization or physician charges connected with prescribing an environmental change.
Clinical Trials, whether FDA-approved or not.
If a member qualifies for public assistance or private benevolence programs, they must apply for the program benefit and receive an eligibility determination that the member does not qualify for the benevolence program before the bill can be considered for sharing. If the member receives assistance through the use of a program, the next three months of their monthly Share Portion will be waived.
Members or providers are required to pre-notify ShareNet of any of the following treatments to be eligible for sharing:
- Cancer Treatment.
- Non-emergency Cardiac Procedures.
- Inpatient/outpatient surgery.
- Non-emergency hospital/facility admission.
- Organ/Tissue Transplant Services
- Maternity.
Providers pre-notify by calling.
Pre-notification of medical bills does not guarantee eligibility or sharing.
Pre-notification enables ShareNet to inform the member about provider options and potential incentives available. If a member or their provider does not pre-notify ShareNet the member may be subject to an additional AUA of $1,000 for the illness or event.
Eligible needs will be approved for sharing when medically necessary. Medically Necessary, which is defined as health care services that are clinically appropriate in terms of type, frequency, extent, site, and duration for the diagnosis or treatment of the member’s sickness or injury and ordered by a Physician exercising prudent clinical judgment for the purposes of evaluation, diagnosis or treatment of that member’s sickness or injury. The Medically Necessary setting and level of service are that which, considering the member’s medical symptoms and conditions, cannot be provided in a less intensive medical setting. Such services, to be considered Medically Necessary, must be no more costly than alternative interventions, including no intervention, and are at least as likely to produce equivalent therapeutic or diagnostic results without adversely affecting the member’s medical condition.
- It must not be maintenance therapy or maintenance treatment;
- Its purpose must be to restore health;
- It must not be primarily custodial in nature;
- It must be a listed item or treatment allowed for reimbursement by CMS (Medicare); and
- ShareNet reserves the right to incorporate CMS (Medicare) guidelines in effect on the date of treatment as additional criteria for the determination of Medical Necessity and/or eligibility of a Need.
- The mere fact that the service is furnished, prescribed, or approved by a Physician does not mean that it is “Medically Necessary.”
- The determination of whether a service, supply, or treatment is or is not Medically Necessary may include findings of the American Medical Association and ShareNet’s own Administrator or medical advisors.
Off-label Drug use is considered Medically Necessary when all of the following conditions are met:
- The Drug is approved by the FDA;
- The prescribed Drug use is supported by one of the following standard reference sources:
- DRUGDEX;
- The American Hospital Formulary Service Drug Information;
- Medicare-approved Compendia; or
- Scientific evidence is supported in well- designed clinical trials published in peer-reviewed medical journals, which
- demonstrate that the Drug is safe and effective for the specific condition; and
- The Drug is Medically Necessary to treat the specific condition, including life-threatening conditions or chronic and seriously debilitating conditions.
“Permitted Sharing Level(s)” means charges for Medical Care that is Medically Necessary for the care and treatment of Illness or Injury, but only to the extent that the fees charged, therefore, are within all applicable limitations and restrictions established -in the ShareNet Guidelines including, but not limited to, the following:
- Hospitals (both inpatient and outpatient services), Ambulatory Surgery Centers, and Independent Facilities: The Permitted Sharing Level for Medical Care established by the Guidelines shall be based upon the average of 150% of the Medicare Allowable Amount for the Medical Care included in the Guidelines and 135% of the Cost of the Medical Care included in the Guidelines; provided, however, that any such Permitted Sharing Level based on the Cost of the Medical Care included in the Guidelines shall be limited to an amount not to exceed 175% of the Medicare Allowable Amount or the amount of Usual, Customary and Reasonable Fees for the Medical Care included in the Guidelines.
- Other Medical & Surgical Services. The Permitted Sharing Level for any general medical and/or surgical Medical Care included in the Guidelines not addressed under the immediately preceding subsection or subsection (d) below may be established or calculated taking into consideration and/or based upon the average of: (i) allowable reimbursement amounts for such Medical Care included in the Guidelines according to the OPPS Reimbursement or other Medicare fee payment methodology plus an additional 50%; (ii) the Costs for such Medical Care included in the Guidelines plus an additional 35%; or (iii) the Usual, Customary and Reasonable Fees as reflected in, or determined by reference to or through the use of any other industry-standard resources or widely recognized data sources, including any resources listed above or any other fee and/or cost information, sources, lists or comparative data published or publicly available (free, for purchase or by subscription), or any combination of such resources that are sufficient, in the opinion of the Claims Delegate, to determine a Reasonable amount of Medical Care included in the Guidelines.
- Facilities Lacking Requisite Benchmarks & Specified Services. In the event Permitted Sharing Levels for Medical Care included in the Guidelines cannot be determined - for technical reasons - in accordance with the two immediately preceding subsections, and for other Medical Care included in the Guidelines specified below, the Permitted Sharing Levels may be determined as follows:
- Pharmaceuticals. The Permitted Sharing Level for pharmacy charges from any Hospital or Independent Facility may be calculated based on pharmaceutical Costs as follows:
- 150% of Cost for pharmaceuticals other than High Dollar Drugs, but not to exceed the Usual, Customary, and Reasonable Fees for such pharmaceuticals; or
- 120% of the Cost for High Dollar Drugs; but not to exceed the Usual, Customary, and Reasonable Fees for such pharmaceuticals.
- Supplies, Implants & Devices. The Permitted Sharing Level for charges for medical and surgical supplies, implants, and devices may be based upon 120% of the Cost to the Hospital or Independent Facility providing such items.
- Professional Services. The Permitted Sharing Levels for Professional Services shall be determined based upon the chart for the professional service identified. This chart is available upon request.
- Dialysis Services and Infusion Therapy. The Permitted Sharing Level for dialysis services and infusion therapy visits (which shall include dialysis, facility services, supplies, and medications provided during treatment) shall be determined by review of the Medicare Allowable Amount for the billing Hospital or Physician in light of clinical considerations pertinent to the patient being treated.
- Medical Care Provided Under Direct Contract. The Permitted Sharing Levels for Medical Care provided by Directly Contracted Hospitals or Physicians will be the rates or fees established under the applicable contract; provided, however, that the amounts of such rates and fees shall be presumed to be Usual, Customary, and Reasonable only to the extent that they do not include otherwise Improper Balances, which charges shall be outside of the Permitted Sharing Levels.
In the event that the Permitted Sharing Level exceeds the actual charge billed for the treatment, service, or supply in question, sharing and payments to providers will be based on the actual billed charge. The Permitted Sharing Level for Medical Care will not include charges related to Unbundling, Errors, Unclear Description, or Misidentification.
Conditions of Sharing
ShareNet is not a substitute for insurance, as may be required by law.
ShareNet is not insurance. However, ShareNet may be used as a substitute for or an exemption from mandated insurance coverage in the following circumstances:
- To satisfy the federal mandate that became effective January 1, 2014, requiring “applicable individuals” to maintain “minimum essential [insurance] coverage.”
- To satisfy a certain state requirement to maintain “minimum creditable [insurance] coverage.”
These are the only exceptions. Otherwise, members must not certify that ShareNet is insurance to avoid purchasing insurance required by law, rule, or regulation, for example, worker’s compensation insurance or sports activity insurance.
If a member has insurance or is eligible/qualified for any insurance benefits or other health or welfare benefits, such as an employment-related health or welfare plan, worker’s compensation insurance, homeowner’s insurance, or fraternal benefits, the member is expected to take all reasonable steps to qualify for such payments and to exhaust benefits available under those resources before submitting a request for sharing.
In certain instances where a Need may have been caused by actions of a third party, the member may be required to assign to ShareNet any and all rights that the member has against all parties responsible for causing the injury or illness. This is up to the total amount members shared on behalf of the member. This includes any and all amounts received by the member from a settlement, judgment, or other awards.
A member can appeal bill-sharing eligibility decisions with which they disagree if he or she believes:
- the medical records were misread, or
- the Guidelines were misapplied, or
- one or more of the member’s providers incorrectly recorded their medical history.
After a review by ShareNet, if the member disagrees with ShareNet’s decision, the member has 90 days to request a review by a Five Member Appeal Panel established by ShareNet and the member may submit a written position statement to the Panel. A teleconference will be held wherein the Panel can ask questions of both the member and ShareNet. A simple majority vote (three out of five) will carry the decision to share or not.
While these Guidelines are not an insurance contract, the Guidelines do outline the manner in which voluntary sharing occurs among ShareNet members. Further, you have authorized ShareNet to exercise reasonable discretion to administer its medical cost-sharing plan according to these Guidelines. Any claim or dispute arising out of, or related to, enforcement of these Guidelines after a member has exhausted his appeals provided for shall be addressed through mediation, with each party to bear their own costs, attorney’s fees, and 50% of the mediator’s fee and with the mediation filing fee to be paid by ShareNet.
If the resolution of the dispute and reconciliation do not result from mediation, the matter shall then be submitted to an independent and objective arbitrator for binding arbitration, with each party to bear their own costs, attorney’s fees, and 50% of the arbitrator’s fee, and with the arbitration filing fee to be borne by ShareNet.
Members agree that these methods of dispute resolution shall be the sole remedy for any controversy or claim arising under these Guidelines or against ShareNet or its agents, employees, and contractors; and expressly waive their right to file a lawsuit for such disputes, except to enforce a legally binding arbitration decision.
Virtual Share Exchange
To make Healthcare Sharing convenient and efficient, ShareNet utilizes a technology platform called a Virtual Share Exchange (“VSE”). The VSE enables all ShareNet members to participate in the Healthcare Sharing process electronically, as well as to monitor the transactional activities of their individual share accounts and the community at large. Your ShareNet membership requires that you activate your own Share Account and enable the Virtual Share Exchange to administer the sharing process on your behalf. By activating your Share Account and accepting the Virtual Share Exchange “Terms and Conditions” and Disclosures, you have given ShareNet, and its Service Agents express permission to conduct financial transactions necessary for the administration of the program on your behalf.
To participate in the ShareNet Community, all members must activate a Share Account on the Virtual Share Exchange Platform. Your Share Account is a virtual account, and all deposited funds are received by America’s Christian Credit Union located in Glendora, CA which holds them “For the Benefit of ShareNet Members”. The Share Account will display your account balances, share transaction history, and other relevant information. The money in your Share Account is insured and is fully controlled by you except as described herein.
To activate your Share Account, you will be required to provide the necessary personal information to comply with U.S. Banking Regulations. Once your information is submitted and verified, you will be required to link your Share Account to one of your External Bank Accounts, such as Bank of America or Wells Fargo. Each month, you will fund your Share Account with an EFT (electronic funds transfer) from your External Bank Account.
ShareNet members will receive a Monthly Share Notice through the VSE Platform to inform them and remind them of the monthly amount that they are to contribute. The monthly amount that you are to contribute (your Total Share Amount Due) is based on the ShareNet Sharing Plan Level that you have selected.
The amount specified in your Monthly Share Notice is transferred through an EFT drawn off your External Bank Account. EFTs are always for the “Total Share Amount Due.” The “Total Share Amount Due” is displayed on every Monthly Share Notice and it will include the current Monthly Share Amount, any Past Due Amounts, and any relevant Service Fees.
The Total Share Amount Due may be paid manually within the VSE Platform or through Recurring EFTs that you configure within the system. You will have the ability to add, edit and delete your Recurring EFTs, as well as your linked External Bank Account at any time.
Your Share Account is a financial account that you own and control. You will have the ability to add, edit and delete your Recurring EFT settings, as well as your linked External Bank Account at any time. You may also choose to have your medical bills “anonymously” shared among the members.
Otherwise, members who share in your medical bills will be able to see your last name when they view the list of members with whom they are sharing.
Participation in the ShareNet Sharing Community is voluntary. This means that when you are selected to participate in a sharing event if you object to that particular sharing event for any reason, you may withdraw and terminate your membership during the three-day publishing period (described below) rather than participate in that sharing event.
Medical Bills that are eligible for sharing are matched, allocated, and published to the membership prior to sharing. To be compliant with regulations and safe harbor statutes, ShareNet implements a member-to-member, or peer-to-peer (P2P), approach to sharing, which means that members share funds directly with one another rather than drawing funds from a pool controlled by ShareNet.
Your medical bills will be submitted to ShareNet by your Medical Providers. ShareNet will process all bills for eligibility per the Guidelines. Eligible bills are then submitted to the Virtual Share Exchange for sharing. Amounts Approved for Sharing are allocated to your fellow members who have been matched to share in (contribute toward payment of) your bill.
Members who have been matched to share your bill will be notified through a process called “publishing” as to the amount that will be withdrawn from their Share Account for the payment of your bill. They will also be notified as to who will be receiving their funds unless you choose the anonymous setting in your Share Account’s Sharing Permissions. Once the three-day publishing period has ended, the amount published to each member is transferred to a Virtual Bill Account for the payment of your bill.
Members who have been matched and allocated to share in another member’s medical bill may withdraw from the membership prior to the expiration of the three-day Publishing Period, in which case no funds will be transferred to the receiving member.
Because a member may refuse to share in a particular medical expense for any reason or no reason, the sharing process remains entirely voluntary for every member. However, as noted above, any sharing refusal requires withdrawal from membership before the end of the three-day Publishing Period.
If you have an eligible medical bill that has been approved for sharing, the VSE will create a Virtual Bill Account for the payment of that bill. Virtual Bill Accounts are unique to a specific medical bill and are linked to your Share Account. Each Virtual Bill Account is unique to a member of your household, a medical provider, and a specific bill. Amounts collected in your Virtual Bill Account(s) are restricted and are displayed as a single line-item transaction in your Share Account.
Virtual Bill Accounts remain open until the Amount Approved for Sharing has been fully collected and transferred to your Medical Provider as payment for your bill or to you as a reimbursement. While Virtual Bill Accounts are aggregated in the transactional view of your Share Account, these funds are restricted and cannot be withdrawn from your Share Account. The transfer of funds from your Virtual Bill Account will be displayed as a single line-item transaction in your Share Account.
In order to process and pay medical bills quickly, ShareNet implements a practice called Distributed Reserving. ShareNet is NOT insurance, so we do not collect and hold medical reserves in a centralized bank account. Instead, the Monthly Share Amount is set at a level to build a small balance (or reserve) in every member’s individual Share Account. These “Distributed Reserves” enable ShareNet to plan for the ebb and flow of medical usage and payments.
Glossary
Administrator – The 3rd party company utilized by ShareNet to process members’ medical bills for discounting and eligibility determination.
Annual Unshared Amount (AUA) – The dollar amount a Household must pay toward their own Eligible Medical Bills during a 12-month period. Members may share in Eligible Medical Bills in excess of the AUA. The AUA 12-month period begins on the Membership Effective Date.
Bill Approved for Sharing – An Eligible Medical Bill that meets the criteria for sharing in the Guidelines and meets the other conditions for sharing, including whether the member’s AUA has been met and other sharing limits have not been exceeded.
Cancellation Date – The month and day membership ends due to the member’s withdrawal or administrative cancellation.
Effective Date – The date the member’s current AUA has begun. This Date may be different from the Membership Date if a Member has switched some elements of their membership.
Eligible for Sharing – Any testing, treatment, procedure, or service that meets the criteria for sharing as established in the Guidelines.
Eligible Medical Bill – An incurred medical bill that meets the criteria for sharing as established in the Guidelines. The Eligible Medical Bill may be reduced by any discounts, fees, or other sources of payment.
Illegal Drugs – any “controlled substance” or “dangerous drug” which has not been legally prescribed and/ or dispensed, or the use of a prescription drug which is not in accordance with the manner in which it was prescribed.
Member – Any member of ShareNet Sharing Programs, including each family member participating in a member household.
Member Household – The related family members participating in a ShareNet Sharing Program.
Membership Date – The date a member’s participation in ShareNet begins. Medical bills incurred after this date may be considered for sharing among members.
Pre-Existing – Medical Conditions are conditions in which signs, symptoms, testing, treatment, or use of medication occurred within 24 months prior to membership start.
Primary Member – An adult member that is the main contact for the household membership.
Provider Fee – The portion of a medical bill that a member pays to a healthcare provider at each visit.
Auto-Share (Recurring EFT) – a Sharing permission enabling a Primary member to set up recurring electronic funds transfers (EFTs) to transfer the Total Share Amount Due specified in their Monthly Share Notice.
External Account – an existing bank account that is linked to the Primary member’s Share Account and is used to transfer via EFT the Total Share Amount Due into the Share Account each month.
Manual Share – a function that enables a Primary member to initiate an “on-demand” EFT to transfer the Total Share Amount Due specified in their Monthly Share Notice.
Permissions – are auto-enable functions (ex. Auto- Share) that are set and managed by the Primary member.
Share Account – the member-controlled virtual account that is linked to both your external account and your deposit account at America’s Christian Credit Union and is used for all sharing transactions and activities.
Grace Period – the number of days between the Share Due Date and Past Due Date.
Monthly Share Amount – the sum of the Share Portion and Required Miscellaneous Portions published in the Share Notice.
Past Due Date – the day of the month that a delinquent Total Share Amount Due becomes past due.
Past Due Reminders – are Share Notice Reminders sent to members who have not paid their Share Notice and are past due.
Payment Reminders – are Share Notice Reminders sent only to members who pay manually, instead of automatically, and only if the Total Share Amount has not yet been paid.
Previous Balance – is the sum of any past due, unpaid amounts published in the Share Notice.
Required Miscellaneous Portion – an amount set by the HCSO to fund certain described activities such as its administrative and program expenses.
Share Due Date – the day of the month by which the Total Share Amount Due must be transferred via EFT in full.
Share Notice – the written notification to a member that details the Total Share Amount Due for the month.
Share Notice Date – similar to a statement date or invoice date, it is the day of the month that the Share Notice is published and distributed.
Share Payment (Funding) – transferring funds (Total Share Amount due) from a member’s External Account to their Share Account.
Share Portion – the portion of the Monthly Share Amount that is collected and used specifically for member-to-member sharing of eligible medical bills.
Total Share Amount Due – the sum of the Monthly Share Contribution Amount (Share Portion and Required Miscellaneous Portion), Optional Portion (auto-enabled by the member), Service Fee, and any past due amount (Previous Balance).
Adjusted Amount – the discounted or repriced amount.
Approved for Sharing – the portion of the Adjusted Amount that is eligible for sharing as per the program Guidelines.
Bill Status – References the processing stage/state of a specific need or bill.
Charge Amount – the gross amount billed by the Medical Provider.
Explanation of Sharing (EOS) – is a notice sent to a member detailing the eligibility status of a bill, any discounted amounts, and what portion of the remaining Charge Amount has been shared by ShareNet members and any remaining amount that must be paid by the member.
Member Responsibility – the portion of the Adjusted Amount calculated to be the member’s responsibility and will not be shared.
Need – is a grouping of medical bills by a medical event such as knee surgery. Individual medical bills may sometimes be referred to as a “Need.”
Published Amount -the portion of the Adjusted Amount that is eligible for sharing and has been published/allocated to the members for sharing.
Received Date – the date that ShareNet receives the medical bill and begins processing the bill for eligibility.
Service Date – the date that the member (patient) received services from the medical provider.
Shared Amount – the Published Amount that has been shared and collected in the member’s Sharing Account.
Sharing (Member-to-Member Transfers) – moving funds from a sending member’s Share Account to a receiving member’s Virtual Bill Account.
Available Balance – the total sum that is available for sharing a new eligible medical bill and/or Withdrawal. It is the Total Balance minus the Pending Balance minus the Restricted Balance.
Debits & Sharing – The “Negative (-)” transactions debited out of the member’s Share Account, which would be Miscellaneous Required Portion (i.e., Debits), Optional Portion, and Share Portion.
Deposits & Credits – The “Positive (+)” transactions that are credited to the member’s Share Account, such as EFT Transfers (i.e. Deposits) and Shared Funds Received (i.e. Credits) that a member might receive to pay their eligible medical bill.
Pending Balance – the sum of EFT(s) that have been initiated but have not yet been posted to the member’s Share Account.
Restricted Balance – the sum of funds that have been credited to the member’s Share Account for purpose of paying an eligible medical bill.
Total Balance – the sum of the Pending Balance, Restricted Balance, and Available Balance in a member’s Share Account.
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