Individuals and Families
Preventative Needs Sharing:
Mammography after age 40 - 6 month waiting period
Colonoscopy after age 50 - 6 month waiting period
Childhood Immunizations - Ages 01-16 - as required by CDC
Choice of $1000, $2000, or $5000.
What is an IUA?
The out of pocket amount the member has prior to cost sharing for the NEED. All qualified medical expenses after IUA is met are shareable at 100% and without an annual or lifetime limit.
The IUA is met one time for the Need and not does not reset annually. It remains open with all medical expenses related to the Need being shared until symptom free for 12 months.
Members usually benefit with an IUA vs a yearly deductible
What is a NEED?
A "Need is the ALL of the medical expenses surrounding a new illness, accident or diagnosis.
Any member household that experiences 3 IUA's within a membership year may have any further medical expense fully shared after only reaching a $500 threshold to further protect the member
Prescriptions for medication(s) that are billed by a provider and are related to a qualified Need are also considered sharable. With your Medical Cost Sharing providers approval, large prescription costs associated with a Need that are filled at the pharmacy can be shared. Does NOT cover maintenance medications.
OptumRx is included .
Pre-Existing Conditions - 24-month look-back: 24-month look-back: a pre-existing condition is considered if you have had symptoms of, been diagnosed with, or been treated for this condition within the past 24 months.
Exceptions for High Blood Pressure, High Cholesterol & Diabetes
as long as there has not been a hospitalization for the condition in the past 12 months and able to control through medication or diet.
Two Initial Unshareable Amounts (IUA’s) are applied to a single maternity need.
Any pre-birth or post birth need of the child will be considered a separate need from the mother’s maternity care.
Pregnancies are considered pre-existing if the pregnancy start date is within the first 60 days of the membership effective date.
Maternity Needs eligible after a 60 day waiting period.
Please see Maternity Sharing Guidelines PDF for more information.
New baby visits are shared
Alternative medical treatments can be shared with the Medical Cost Sharing community.
These alternatives generally should be considered safe and effective while being an alternative to a traditional treatment plan.
Needs may be considered shareable pending prior written approval by your Medical Cost Sharing provider.
Member is required to demonstrate the proposed value of the alternative treatment.
50 monthly surcharge per household.
Furthermore, there is a sharing limit for smokers age 50 or more of $50,000 for Heart Conditions, Cancer, COPD & Stroke.