*Official Member Guideline

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.

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. 

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.

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.

Audiological

Audiological treatment to correct hearing loss is eligible for sharing.

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 may 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.

Basal & Squamous Cell Cancer

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

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.

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.

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.

Cosmetic Surgery

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

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.

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.

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 to120 days per medical need. Sleep apnea equipment is not shareable.

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.

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.

Genetic Testing

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

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.

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.

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.

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 up to $3,000. Injections related to gender transitioning or sex reassignment therapy are ineligible for sharing.

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.

Joint Replacement Treatment

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

Laboratory Tests & Checkups

Laboratory tests and checkups are considered part of an eligible sharing request when prescribed by a licensed medical provider.

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. 

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.

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.

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.

Organ Transplants

Organ trasnplants are eligible for sharing; however, they are subject to limitations for pre-membership medical conditions. See Pre-Membership Medical Conditions Guidelines for more information. 

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.

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 one-time 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.

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.

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.

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.

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.

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.

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)

Varicose Veins

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

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.