ClearShare-Member-Guidelines-2022.07.11.pdf

ClearShare Member Guidelines VERSION 2 UPDATED ON 2/1/2023 TABLE OF CONTENTS History ...................................................................................................................... 3 About ClearShare ..................................................................................................... 4 Statement of Beliefs ................................................................................................. 5 Membership Eligibility ............................................................................................. 6 Enrollment Requirements ........................................................................................ 8 Member Responsibilities .........................................................................................10 How Needs are Shared ........................................................................................... 11 Pre-Membership Medical Conditions ..................................................................... 14 Specific Sharing Qualifications ............................................................................... 15 Medical Expenses Ineligible for Sharing ................................................................. 21 Maternity Needs .................................................................................................... 23 Submission of Medical Needs ................................................................................ 24 End of Life Assistance ............................................................................................. 25 Appendix A: Defined Terms .................................................................................... 26 Disclaimers ............................................................................................................. 31 2 Our History Historically, healthcare hasn't been centered around the best possible member experience. It’s often complex, confusing, and clumsy. It’s hard to manage and overwhelming to try and understand. On top of that, it’s enormously–and sometimes prohibitively–expensive. We believe that millions of families are spending too much money on healthcare when they could be investing in other things that are important to them, like their children, their home, their retirement, and their future. We know that there’s a better way: like-minded people who care about their health join a community to share in medical needs without a profit motive. The concept of healthcare cost sharing dates back to the 1700s, when small religious communities would pool their money to help bear the burdens of other individuals’ medical costs during hard times. Eventually, healthshares grew to serve larger communities while following similar principles. Modern healthshares have been successfully meeting member’s healthcare needs for the last 30 years, and today more than two million people participate in a healthshare. In April 2022, ClearShare was formed as a not-for-profit organization* devoted to the success of individuals’ health. ClearShare does not discriminate based on background, nationality, ethnicity, or denomination. We offer medical cost sharing with our members for a broad range of health needs. ClearShare has three primary goals: 1. 2. 3. Offering members the lowest fixed amount each month and lowest out-of-pocket costs when using the membership Allowing members the broadest access of providers Giving members a simple, fair, and easy-to-understand experience We’re not looking for ways to trick our members or not share in their medical needs. We measure our success as the number of people that we help and the degree to which we help them. We also believe in paying providers for our member’s eligible needs quickly to foster a good reputation among providers and ease the administrative burden on our members. We care about our member’s health just as much as you do and our mission is to bring like-minded individuals together to lower healthcare costs for all. *ClearShare was formed and approved as a non-profit in the state of Missouri. Our 1023 non-profit 501(c)(3) tax exemption application is pending approval by the Internal Revenue Service. About ClearShare ClearShare is founded to support individuals who share a similar faith in a higher power’s love for people and care for the quality of healthcare provided to families and individuals. Individuals pay their monthly contribution and medical needs are shared as they arise. ClearShare will utilize several cost-containment strategies to help Members have the lowest possible required contributions and the Member pays the least out of their wallet. ClearShare membership is open to individuals from all backgrounds, nationalities, ethnicities, and faiths. We welcome all members who agree to our Statement of Beliefs. Statement of Beliefs A. I believe in a higher being or power. B. I understand that ClearShare is a membership-based, non-insurance community of individuals established for the purpose of sharing eligible healthcare expenses between Members, as described in the Membership Guidelines. C. I believe in personal responsibility to pursue a healthy lifestyle and not abuse my body by taking illegal recreational drugs, excessive alcohol use, driving while intoxicated, or otherwise abusing my body or that of my family with harmful acts. I believe it is wrong to abuse others and that any mental, emotional, verbal or physical abuse of a family member is morally wrong. D. I believe that ClearShare is a benevolent organization dedicated to helping lower the cost of healthcare and that it is not an insurance company therefore it cannot legally guarantee payment of medical expenses. E. I acknowledge that ClearShare considers itself accountable to a higher power to ensure all members from all backgrounds, nationalities, ethnicities, and faiths are treated fairly and with the highest ethical conduct. If you share these beliefs we welcome you to join our membership community. 5 Membership Eligibility Membership eligibility in ClearShare is primarily based on two factors: 1. Adherence to the ClearSare Statement of Beliefs 2. Participation in the community by submitting monthly contributions After committing to these primary obligations, prospective members are eligible to enroll in the ClearShare community. Membership may begin on a date elected by the prospective member or specified by ClearShare. The prospective member’s monthly contribution must be received within 15 days of the agreed upon start date. The first monthly contribution must be received before the membership is considered active. 6 Membership Eligibility 1. ClearShare Statement of Beliefs Members of ClearShare commit to abide by a set of personal standards as outlined in the ClearShare Statement of Beliefs. If a violation of the Statement of Beliefs is discovered through review of a member’s submitted medical records, all cost sharing for the needs of that member will be put on hold. This hold will begin on the date in which the violation was discovered or recorded in the member’s medical records. A notification of the hold and an explanation of the discovery will be issued to the member. The member will be granted 30 days to submit documentation supporting compliance with the Statement of Beliefs. If the submitted documentation does not satisfactorily demonstrate compliance with the Statement of Beliefs, the member will automatically be withdrawn from the sharing program and membership will be revoked. If membership is revoked due to a violation of the Statement of Beliefs, ClearShare will not return the offending member’s contributions received prior to the date of withdrawal. 2. Participation by monthly contributions To participate in the member-to-member medical cost sharing community, members must submit the monthly contribution amount associated with their level of membership. Members have multiple options for submitting their monthly contributions. Individual members can make contributions directly to ClearShare. For members who enroll in ClearShare through their workplace, payments can be made through their employer. All member contributions are voluntary, but the monthly contribution is required to be active and eligible for sharing. Monthly contributions must be received by the last day of the month after the billing date. If a monthly contribution is not received by the last day of the billing month, the membership will become inactive, and the member will be withdrawn from the medical cost sharing community. Any member that has been withdrawn may reapply, provided they meet all enrollment and eligibility requirements. Once the member reapplies and membership is reinstated by ClearShare, the member will become eligible to participate in cost sharing. All member needs occurring after the membership is inactivated and before reinstatement will be ineligible for cost sharing, and any medical conditions existing before the date of reinstatement will be considered pre-membership medical conditions. Any member whose membership has been inactivated three times will not be eligible to reapply. 3. Qualiﬁcation To be qualified for membership, an applicant must meet all criteria set forth in the membership guidelines and the membership enrollment form. If at any time it is discovered that a member did not submit a complete membership enrollment form, the incomplete form could result in either a retroactive membership limitation or a retroactive denial of membership. While member health status has no effect on eligibility for membership, there are limitations on medical cost sharing for some conditions that existed prior to a member’s effective date. Primary members must be at least 18 years old to enroll in their own plan, and all members must be under 65 years old. 7 Enrollment Requirements ClearShare offers different enrollment types for individuals and families. Monthly contributions are based on the enrollment type, annual maximum, and member age. This section outlines the different household memberships and who is eligible for enrollment therein. 1. Determination of Household Membership There are four tiers of membership, and member contributions are calculated depending on the participating members of a household. ● ● ● ● Member Only: An individual member of ClearShare Member + Spouse: A member and their spouse Member + Children: A member and their dependent child or children Member + Family: A member, spouse, and any dependent children 2. Dependents An unmarried dependent may participate under a combined membership with the head of household through the age of 25. Children born into a membership due to an eligible maternity need may participate under a combined membership. Under a combined membership, the head of household is responsible for ensuring that each individual participating under the combined membership complies with membership guidelines and the ClearShare Statement of Beliefs. Once a dependent reaches the age of 26 or marries, that dependent is no longer eligible to participate under the combined membership. A dependent who wishes to continue participating as a member with ClearShare may complete an enrollment form. Any medical needs that occur between the time when a child leaves their parent’s membership and enrolls in their own membership are not shareable. If a dependent ages out of their ClearShare membership but chooses to re-enroll at a later date, they will be subject to the limitations associated with pre-membership medical conditions. 3. Newborns Newborns whose birth is part of a shareable maternity need must be enrolled by the parent within 30 days of birth. In the case of a change in household enrollment type, the monthly contribution amount will be adjusted automatically for the next billing cycle. If the parent does not enroll their newborn within 30 days, any conditions present at birth or that occur before the child’s enrollment date will be considered pre-membership medical conditions. Newborns who are not born as a part of a shareable maternity need must be enrolled manually in a ClearShare membership. The newborn’s membership will begin on the date of enrollment but can be no sooner than seven days after delivery. Any genetic conditions or complications for newborns not born as part of a shareable maternity need are considered pre-membership medical conditions and subject to the same limitations as defined in the “Pre-Membership Medical Conditions.” 8 Enrollment Requirements 4. Adoption ClearShare regards adopted children the same as biological children regarding membership. Any physical conditions of which the adoptive parent are aware prior to the legal adoption of the child are considered pre-membership medical conditions and are subject to the sharing limitations and phase-in period outlined in the Member Guidelines. Adopted children cannot be added to a ClearShare membership prior to birth. 5. Grandchildren A grandchild (or grandchildren) may be included as part of their grandparents membership if they meet the following criteria. 1. 2. 3. The grandparent has legal custody of the grandchild. The grandchild lives with their grandparents at least nine months out of the year. There is no other agency, person, or group responsible for the grandchild’s medical needs. 6. Tobacco ClearShare households with one or more tobacco users are required to contribute a higher monthly contribution to maintain membership. The monthly tobacco surcharge is $50 per household. A household member who has used any tobacco product one or more times a month within the past year is considered a tobacco user. Tobacco products include, but are not limited to, cigarettes, cigars, chewing tobacco, snuff, vape products, and pipe tobacco. Smoked cannabis products are considered tobacco for the purposes of the tobacco surcharge. 7. Membership Add-Ons At the time of enrollment, members may choose to include an Advanced or Basic add-on to their membership. These add-ons provide sharing for certain day-to-day services as listed in their respective guidelines: Advanced Add-On Member Guidelines and Basic Add-On Member Guidelines. Members can only change to or from an Advanced or Basic add-on at their membership renewal, or during annual Open Enrollment from November 1 through December 31. 9 Member Responsibilities All members of ClearShare share certain responsibilities to remain a part of the sharing program. Because the actions of one member can affect the entire community, each member will be held accountable for following these standards. 1. Member Contributions Monthly membership contributions should be made in a timely manner. If contributions are not made by the last day of the month after the billing date, the membership will be inactivated, and any needs will not be shareable. See “Participation by Monthly Contributions” for more information. 2. Proper Submission of Medical Needs to ClearShare For ClearShare to share in a member’s medical expenses, the member is responsible for submitting a completed and correct need request form within six months of the treatment date to ClearShare. This process is outlined in the section titled “Submission of Medical Needs.” 3. Trust & Accountability ClearShare members are expected to act with honor and integrity. Members should not falsify medical needs or medical records or use deceptive practices. If a member abuses the trust of ClearShare and its members, their membership may be revoked. 10 How Needs are Shared This section explains how the shareable amount of a member’s medical expenses will be determined. Medical needs are submitted on a per member, per need basis. Medical needs may be injuries or illnesses that result in medical expenses. These medical expenses may be incurred by receiving medically necessary treatment from licensed medical professionals and facilities, such as physicians, emergency rooms, and hospital facilities. When a member has a medical expense to be shared, the member must submit original, itemized bills for the medical expense within six months of treatment. Bills submitted more than six months after the service date of treatment will not be shareable. There is no lifetime limit on the number of conditions or the total dollar amount that may be shared. 1. Determination of a Need Expenses related to the same medical condition, whether expenses for a single incident or separate incidents, will be shared as one need. The related expenses will accumulate toward the total need amount. 2. Annual Maximum The annual maximum is the amount that a member will pay before the ClearShare community shares in medical expenses. The Annual Maximum is also known as your personal responsibility. ClearShare has three primary levels of personal responsibility: $1000, $2500, and $5000. The lower your personal responsibility, the higher your monthly contribution will be. All qualifying medical expenses submitted after the Annual Maximum is met are shareable with the ClearShare community at 100%. There is no annual or lifetime limit. You will not need to pay the Annual Maximum again until the new calendar year begins. Additionally, you are only responsible for the Annual Maximum once each calendar year. For members who selected ClearShare’s Advanced or Basic add-on, some shareable services do not accumulate towards the Annual Max, as defined in their respective guidelines: Advanced Add-On Member Guidelines and Basic Add-On Member Guidelines. Service copays are not included in the annual maximum. For members who are also part of an HSA MEC, service related costs that apply to the member’s deductible are not part of the annual maximum. 11 How Needs are Shared 3. Family Annual Maximum If you have family members on the plan, they have to meet their own Annual Max until the overall Family Annual Max has been met. Once the household has paid up to its Family Annual Max, the ClearShare community will share in eligible medical expenses at 100%. Annual Max: $1,000 Annual Max: $2,500 Annual Max: $5,000 Member + Spouse A member and their spouse. Family Annual Max: $2,000 Family Annual Max: $5,000 Family Annual Max:: $7,500 Member + Children A member and their dependent child or children Family Annual Max: $2,000 Family Annual Max: $5,000 Family Annual Max: $7,500 Member + Family A member, spouse, and any dependent children Family Annual Max: $3,000 Family Annual Max: $7,500 Family Annual Max: $10,000 If adding dependents to your membership changes your tier, your Family Annual Maximum will increase when the dependent becomes active on your membership. If removing dependents from your membership changes your tier, your Family Annual Maximum will not decrease until your membership renewal. Any payments made for the removed dependent's Annual Max will remain and count towards the Family Annual Max. 12 How Needs are Shared 4. Changing your Annual Maximum Members may choose to change their Annual Maximum at their membership renewal or during annual Open Enrollment, November 1 through December 31. 5. Maximum Shareable Amount There is no annual or lifetime maximum shareable amount for any member or membership household. ClearShare has a systematic way to handle large needs and has budgeted to address large needs. 6. Insurance Companies & Government Entities Insurance companies and government entities are primarily responsible for the payment of a member’s medical expenses. Members who are eligible for benefits through either insurance or government assistance must contact ClearShare before submitting their medical need. 7. Active Membership To participate in medical cost sharing with the ClearShare community, a membership must be active. Membership is considered active when the member has paid their monthly contributions on time and is in good standing with Clearwater. For a medical need to be shared, the membership must be active during the dates of service, when medical bills are received, and at the time the Annual Maximum is paid. If a membership deactivates before the determination of sharing is made, the bills will not be shared with the community. Any pre-membership condition limitations are applied based on the first date of active membership. 8. Late Fees and Interest Any late payment fees or interest charges that may accrue to medical bills before the member meets their Annual Maximum are the member’s responsibility – they are not shareable. Additionally, any late fee or interest charges caused by a member’s delay in providing necessary documentation to ClearShare are not shareable. 9. Appeals If a member believes that a limitation was incorrectly placed on member sharing, an appeal may be submitted. Members may submit an appeal and provide supporting medical evidence to have the membership limitation removed. All appeals are reviewed by a committee that includes at least one ClearShare board member. To file an appeal, send the medical evidence, an explanation of why you feel that the limitation was placed unfairly, and any supporting documentation to ClearShare. 13 Pre-Membership Medical Conditions To keep membership contributions low for all members, ClearShare implements a waiting period for sharing of medical conditions that exist prior to enrollment in a ClearShare membership. This section defines medical conditions prior to membership and outlines the sharing limitations. 1. 12 Month Treatment Free: Needs that arise from conditions that existed prior to membership are only shareable if the condition was regarded as cured and did not require treatment for 12 months prior to the effective date of membership. Any illness or injury for which a person has been: ● ● ● ● 2. Examined Taken medication Had a diagnostic test performed or ordered by a physician Or received medical treatment Exceptions for High Blood Pressure, High Cholesterol, Diabetes, Cancer, Heart Disease, Stroke, COPD: High blood pressure, high cholesterol, and diabetes (types 1 and 2) will not be considered pre-membership medical conditions as long as the member has not been hospitalized for the condition in the 12 months prior to effective date and is able to control it through medication and/or diet. Cancer, Heart Disease, Stroke, and COPD are only shareable if the condition was regarded as cured and did not require treatment for 5 years prior to the effective date of membership. 3. Exceptions for Other Medical Conditions ClearShare recognizes that each member’s situation is different. ClearShare reserves the right to make exceptions for certain medical conditions on a case-by-case basis. ClearShare makes decisions in service to the community as a whole. 4. Pre-Membership Medical Condition Phase-In Period Pre-membership medical conditions have a phase-in period wherein sharing is limited. Starting from the initial effective date, members have a one-year waiting period before pre-membership medical conditions are shareable. After the first year, pre-membership medical condition needs are eligible for sharing on a limited basis, with the amount increasing each membership year. ClearShare attempts to negotiate all medical bills received. Even if a pre-membership condition is not shareable, members may still receive discounts for their service through negotiation. Shareable amounts for pre-membership medical conditions: ● ● ● ● Year One: $0 (waiting period) Year Two: $25,000 maximum benefit per pre-membership medical condition Year Three: $50,000 maximum benefit per pre-membership medical condition Year Four: $125,000 maximum benefit per pre-membership medical condition After year four of membership, expenses related to pre-membership medical conditions will remain shareable at a maximum of $125,000 in a 12-month rolling period and resetting each membership year based on effective date. 14 Speciﬁc Sharing Qualiﬁcations Member needs not associated with a pre-membership medical condition are generally shareable. The following list reflects limitations on sharing for certain conditions or requirements for certain expenses to become eligible. All shareable expenses are subject to the member Annual Maximum. 1. Alternative Medical Practices Alternative medical treatments may be shared with the ClearShare community with prior written approval from ClearShare. Alternative medical treatments without written approval may not be shareable. 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 ClearShare 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 (ClearShare can help obtain doctor notes) Estimated costs (ClearShare can help obtain the estimated costs, if appropriate) ClearShare considers alternative medical treatment plans on an individual basis and may put a cap on visits or shareable costs depending on the service. 2. Alcohol and Drug Abuse Treatment Treatment for alcohol abuse, substance abuse, or chemical dependency is shareable up to $3,000 per member. 3. Ambulance Transports Ambulance transports are shareable as part of a need when they are required in relation to a specific shareable illness or injury. 4. Audiological Audiological needs to correct hearing loss are shareable. 15 Speciﬁc Sharing Qualiﬁcations 5. Automobile Accidents 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 ClearShare receives documentation to reflect a lack of liability or partial payment. 6. Cataract Surgery Cataract surgery is treated as a pre-membership medical condition and subject to a one-year waiting period before it is shareable. Each eye is considered a separate need and subject to an Annual Maximum. 7. Chiropractic 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. 8. Chronic Pain Therapy Services related to chronic pain therapy have the same limitations as an alternative medical practice. They are shareable as part of a related eligible need, and members must get prior approval from ClearShare for the number and type of sessions. See the limitations on injections for more information. 9. Congenital Conditions Congenital conditions of children born outside a shareable maternity will be considered a pre-membership medical condition and will be subject to the waiting period for cost sharing. 10. Cosmetic Surgery Expenses related to cosmetic surgery are shareable only from disfiguration due to a shareable injury or illness. 11. Emergency Visits Emergency room visits are generally shareable separately or in conjunction with an eligible medical need 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 may not be shareable. Members with non-emergent needs should seek out other treatment options such as doctor visits, telemedicine, urgent care clinics, or other appropriate care. Non-emergent emergency room visits may not be shareable. Seeking proper non-emergent care reduces emergency room visits and the financial strain on the entire community. IF YOU HAVE A LIFE-THREATENING EMERGENCY, YOU SHOULD GO TO THE EMERGENCY ROOM. Urgent but non-emergent needs can be treated at Urgent Care. If you are unsure, contact ClearShare for guidance. 16 Speciﬁc Sharing Qualiﬁcations 12. Genetic mutation Needs resulting from a genetic mutation that existed prior to membership are subject to the same limitations as other pre-membership medical conditions. If the member did not receive a diagnosis, require treatment, or take medication for the genetic mutation in the 12 months prior to membership, needs related to the condition are considered shareable without pre-membership condition limitations. 13. Genetic Testing Genetic testing will only be considered for sharing if it is required for the personal treatment of a shareable condition, such as breast cancer. 14. Home Healthcare 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 $5,000. 15. Hospice Care Hospice care is shareable for 90-day periods when ordered by and under the care of a licensed care professional and upon physical approval or certification of terminal illness. 16. Hospitalization Hospitalization is shareable at a semi-private room rate. If a medical provider prescribes ICU or quarantine, those expenses are also shareable. 17. Hyperbaric Therapy 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. 18. Injections 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. 19. 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 ClearShare. 17 Speciﬁc Sharing Qualiﬁcations 20. Joint-Replacement Surgery Joint replacement surgery for degenerative or arthritic conditions is treated as a pre-membership medical condition and is subject to the waiting and phase-in periods. 21. Laboratory Tests and Checkups Laboratory tests and checkups are shareable as part of an eligible need when prescribed by a licensed medical provider. 22. Long-Term Care and Skilled Nursing Long-term care and skilled nursing are shareable when prescribed by a licensed medical provider for recovery from a shareable injury or illness. Sharing for these services is limited to 90 days per medical need. 23. Medical Equipment 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. 24. Medical Supplies 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. ClearShare 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. 25. Naturopathic Naturopathic care may be shareable pending written approval from ClearShare. Any expenses incurred prior to receiving written approval are not shareable. 26. Newborn Care Well newborn care is shareable as part of the mother’s claim while the mother is confined for delivery not to exceed forty-eight (48) hours for a vaginal delivery or ninety-six (96) hours for a cesarean delivery. Such care shall include, but is not limited to: ● ● Physician services Hospital services A newborn child is eligible for membership from the date of birth, provided the ClearShare Member completes and submits all required forms that adds the newborn child and changes to a family membership, if necessary, within the first 30 days of the child’s birth date. Routine care for a newborn without complications is part of the newborn’s need. NICU care and other complications are treated as a separate need of the baby. Expenses related to circumcision are excluded from sharing. 18 Speciﬁc Sharing Qualiﬁcations 27. Nutritionists Expenses related to nutritionist services are not shareable unless prescribed by a licensed medical provider. ClearShare must provide approval for nutritionist services prior to sharing. 28. Occupational Therapy Occupational therapy is shareable for inpatient treatment and up to 35 outpatient sessions per need, up to $7,500. Occupational therapy must be prescribed by a licensed medical provider to be shareable. 29. Organ Transplants Organ transplants are shareable; however, they are subject to limitations for conditions existing prior to membership. 30. Physical Therapy Physical therapy is shareable for inpatient treatment and up to 35 outpatient sessions per need, up to $7,500. Physical therapy must be prescribed by a licensed medical provider to be shareable. 31. Prescriptions 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 ClearShare the prescription is related to the treatment of a shareable need prescription costs accumulate to $500 monthly Sharing for these prescriptions is limited to the duration of their membership period. Other prescription costs are generally not shareable. Members who have questions about prescriptions should contact ClearShare. 32. Speech Therapy Speech therapy in relation to a shareable 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. Speech therapy must be prescribed by a licensed medical provider to be shareable. 19 Speciﬁc Sharing Qualiﬁcations 33. Sports 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. 34. Suicide and Attempted Suicide ClearShare encourages members to take advantage of our Talkspace 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, ClearShare 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. 35. 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. 36. Tobacco Use 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: ● ● ● ● Stroke Cancer Heart conditions Chronic obstructive pulmonary disease (COPD) 37. Vision ClearShare may share in vision-related expenses that are deemed medical. 38. Weight Reduction Expenses related to weight reduction are shareable if prescribed by a licensed medical provider and approved by ClearShare- up to $3,000 per need. 20 Medical Expenses Ineligible for Sharing The ClearShare community chooses not to share in some medical expenses. Decisions for sharing eligibility are made to benefit the community as a whole, to keep monthly contributions low for our members, and to share in medical expenses based on our Statement of Beliefs. The following expenses are excluded from sharing with the ClearShare community. 1. Abortion Expenses of the abortion of a living, unborn baby are not shareable. 2. Acupuncture Expenses related to acupuncture and acupuncture services are not shareable. 3. ADHD, ADHS, and SPD Treatment Expenses for prescriptions related to ADHD, ADHS, and SPD are not shareable. 4. Allergy Treatments Allergy testing and medication is excluded from sharing. Needs that arise out of non-seasonal allergies, such as an emergency room visit for an allergic reaction, are considered shareable. 5. Dental 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. 6. Diabetic Medication and Supplies Any medical expenses related to supplies, testing, medication, or other implements used to treat insulin-dependent diabetes are not shareable. 7. Fertility Expenses related to fertility evaluations and treatments are not shareable. 8. Genetic Screening Genetic screenings are not eligible for sharing. 9. Hearing Aids Expenses related to hearing aids are not shareable. 10. 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. 11. Medical noncompliance 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 of the need and/or any complications that arise. The need will be subject to review, and a determination made. 12. 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. 13. Mental Health Expenses related to medications or other treatment for any mental health illness or condition are not shareable. Mental health conditions may include anxiety, depressions, mental illnesses, and other psychological conditions. *Through Talkspace, ClearShare members may have access to regular, preventive mental health consultations. 14. Sleep Apnea Sleep apnea equipment and testing is not shareable with the ClearShare community. 15. Sterilization Effective sterilization, such as tubal ligation and vasectomy, is not shareable. 16. Surrogacy Expenses related to a surrogate pregnancy, whether or not the surrogate is a member, are not shareable. 22 Maternity Needs As a general rule, maternity needs are shareable and are treated like any other medical need. 1. General As with any other medical need, expectant mothers pay their Annual Maximum for all expenses related to their maternity need. Shareable expenses may be related to miscarriage, prenatal care, postnatal care, and delivery. STD screenings prescribed by a licensed practitioner as part of routine prenatal care are shareable as part of the maternity need. Maternity need requests must be submitted within 30 days from the date the member’s pregnancy is verified. 2. Separate Needs Any need of the baby, whether occurring before or after birth, including congenital conditions, is separate from the mother’s maternity need. Expenses for any pregnancy or birth-related complications of the mother will be shared as part of the maternity need. 3. Early Sharing Requests A maternity care provider may reduce normal charges if a member prepays some or all of the bill. If this is the case, ClearShare will consider sharing the maternity need prior to delivery. To be considered for early sharing, the member must submit an estimate from the provider with the need request form. 4. Annual Maximum Payment Like any other shareable medical expense, the Annual Maximum must be paid prior to any cost sharing. Any late payment fees or interest charges incurred because of a late Annual Maximum payment are not shareable. 5. Home Births Home births typically incur fewer expenses. If the costs are significantly lower for a home birth than for a hospital birth and the member is under the care of a licensed care provider, ClearShare may partially waive the Annual Maximum for the maternity need. 6. Pregnancy Prior to Membership Conception that occurs prior to membership or within the first 60 days of membership is eligible for sharing, but with a $50,000 limit. In this event, medical expenses for the newborn are also eligible for sharing, but with another $50,000 limit. ClearShare requires notes from the first provider visit in order to verify the conception date. 7. Premature Birth The baby’s needs are fully shareable, even if the baby is born prematurely. Any services not included in a standard maternity need would be considered a separate need of the baby. 23 Submission of Medical Needs ClearShare strives to share in its members’ medical needs in a timely, accurate manner. To do this, it is crucial for members to submit medical needs correctly and include all required documentation. 1. Submitting a Need Request Need requests should be submitted through ClearShare’s website: ClearShareHealth.org/need-request. Need requests should be submitted as soon as possible. Most non-emergent need requests, such as surgical procedures, should be submitted 14 days prior to the date of service. For any help with this process, members may contact ClearShare directly during business hours at 877-405-2926 or [email protected] 2. Required Documentation Need requests must contain all required documentation, including but not limited to the following: ● ● ● 3. Itemized bills Proof of Annual Maximum payment Medical records and other additional documents Time Limit for Providing Documentation Original, itemized bills should be submitted promptly to ClearShare along with the need request form in order for the need to be processed as soon as possible. In order to be shared, bills and need requests must be submitted within six months of the date of service. 4. Meeting the Annual Maximum Needs are only shareable with ClearShare after the member has met their Annual Maximum. Members should provide documentation to ClearShare of all payments that may contribute toward the member’s Annual Maximum. 5. Paying at the Time of Service To make your experience as simple as possible, ClearShare can pay providers over the phone at the time of service. 6. Negotiating Medical Bills ClearShare prefers to pay providers quickly and negotiate the best rates for healthcare services. This helps ClearShare keep rates low for members. Members should inform ClearShare about any potential cash-pay discounts and consult with a member needs team associate prior to signing any payment arrangements. ClearShare is happy to participate in cost negotiations for its members. 24 End of Life Assistance If any member dies after one year of uninterrupted membership, ﬁnancial assistance will be provided to the surviving family. The ClearShare member community will provide assistance upon receipt of a copy of the death certiﬁcate. Financial assistance will be provided to the surviving family as follow: ● ● ● $10,000 upon the death of a primary member $10,000 upon the death of a dependent spouse $2,500 upon the death of a dependent child 25 Appendix A: Deﬁned Terms Additional Giving Voluntary contributions by members for the purpose of offsetting expenses for other members’ unshareable needs. Annual Limit The maximum amount shared for eligible needs per participating member per year. ClearShare does not have annual or lifetime sharing limits for our members unless specifically stated in the Member Guidelines. Annual Maximum The specific financial amount that members are required to bear on their own prior to any amount that may be eligible for sharing. Application Date The date ClearShare receives a complete membership application. Benevolent Fund A fund maintained by ClearShare created from the contributions of members for the exclusive purpose of reimbursing eligible needs of members. Benevolent Organization An organization whose primary purpose is to care for the needs of the persons/members who make up the membership. A benevolent organization is not an insurance company. Congenital Condition Any disease or physical abnormality present at birth or that is identified or diagnosed within the first year of life. Contribution List A list of members who are being billed by payroll deduction through a company opposed to direct billing from ClearShare. Date of Service The day medical services were rendered on behalf of a participating member. 26 Dependent The head of household’s spouse or unmarried child(ren) under the age of 26, who are the head of household’s dependent by birth, legal adoption, or marriage, and who are participating under the same combined membership. Unmarried children under 26 years of age may participate in the membership as a dependent. Effective Date The date a person’s membership begins. ClearShare members also have the effective date as the billing due date. Eligible Need A medical need that qualifies for sharing via the contributions of ClearShare members. Head of Household The oldest participating member in the household. Household Membership One or more family members participating under the same membership. Healthcare Sharing A membership-based, non-insurance arrangement established for the purpose of sharing legitimate healthcare expenses between members. Inactive Member A contributor, and contributor’s dependents, if applicable, who has/have not submitted monthly contributions in the manner established by the Member Guidelines. An inactive member is not eligible for sharing. Ineligible Need A need disqualified from voluntary sharing of contributions from member contributions due to a policy set forth in the Member Guidelines. Licensed Medical Professional An individual who has successfully completed a prescribed program of study in a variety of health fields and who has obtained a license or certificate indicating his or her competence to practice in that field (MD, DO, ND, NP, PT, PA, Chiropractor, etc.) Lifetime Limit The maximum amount shared for eligible needs over the course of an individual members’ lifetime of membership. 27 Maternity Need A need request that must be submitted once a member becomes pregnant within 30 days of confirmation of pregnancy from a licensed medical professional. Maximum Shareable Amount The maximum dollar amount (limit) that can be shared for any one need. Certain medical needs have a maximum shareable amount as described in the Guidelines. Medically Necessary A service, procedure, or medication necessary to rest or to maintain physical function and that is provided in the most cost-effective setting consistent with the member’s condition. The fact that a provider may prescribe, administer, or recommend services or care does not make it medically necessary. This applies even if it is not listed as a membership limitation, or in the Member Guidelines. To help determine medical necessity, ClearShare may request medical records and information from licensed medical professionals. Member(s) A person or people (or dependent thereof) who has agreed in writing to abide by the requirements of ClearShare and is thereby eligible to participate in the sharing of medical needs with other members in accordance with the Member Guidelines and membership type. Membership This term applies to the collective body of all active, participating members of ClearShare. Membership Cancellation Request A request by a member to ClearShare that their membership be canceled. The request must include the reason for cancellation, and the requested month in which the cancellation of the membership is to be effective. ClearShare requires a 30-day notice prior to your payment draft date. ClearShare does not prorate cancellations or give refunds. Cancellations become effective on the last day of your monthly billing anniversary following the timely receipt of your membership cancellation request. Members have 30 days from the membership cancellation date to reactivate membership in order to qualify for continuous membership. For example, employers who terminate employee memberships. Membership Commitment The required principles and ongoing behavioral code attested to by members as required for membership. Membership Responsibility Amounts Amounts needed to be paid by the member for medical costs that are not shareable with the ClearShare community. 28 Membership Update A communication from the member to ClearShare providing any changes to the details of their membership information (ie: change of address, phone number, etc.). The change request or update may take up to three business days to complete. Once a representative of ClearShare approves the requested changes, the approved changes may go into effect on the monthly membership anniversary. Membership Limitation A specified medical condition for which medical needs arising from or associated with the condition are ineligible for reimbursement from the Benevolent Fund. An associated condition is one that is caused directly and primarily by the medical condition that is specifically ineligible. The membership limitation will be issued during the application process and may be subject to medical record review. Membership limitations (excluding cancer) do not apply to office visits/urgent care. Member Plan A variety of sharing options are available with different annual maximums and sharing limits, as selected in writing on the membership application or enrollment portal and approved by ClearShare. Membership Withdrawal When a membership has been or will be canceled due to the submission of a Membership Cancellation Request Form, a violation of the ClearShare’s Statement of Beliefs, or non-receipt of a voluntary monthly contribution or annual membership fee for more than 10 days past the date such payment was due. Such cancellation of membership is referred to as membership withdrawal. Monthly Contributions Monetary contribution given voluntarily and placed in the care of ClearShare by a member to maintain active membership and to be disbursed for the eligible needs of its members in accordance with the Member Guidelines. Need Request A request that is required to process medical needs for accidents, injuries, or medical conditions that result in medical costs. Need requests can be submitted to ClearShare: ClearShareHealth.org/need-request. The need request must be submitted to ClearShare within six (6) months of the need to be eligible for sharing. Non-Affiliated Provider A non-network, licensed medical professional or facility as determined by ClearShare. Office Visit Sick visits, wellness visits, specialists, and urgent care are generally considered to be office visits. The medical bill must include an office visit CPT code for the need to qualify as an office visit. 29 Plan Administration A collaborative process of planning, evaluating, facilitating, coordinating, and advocating for options and services to meet a participating Member’s Eligible Needs through available resources to promote quality, cost-effective results. Pre-Membership Medical Condition Any illness or accident for which a person has been examined, taken medication, has a diagnostic test performed or ordered by a physician, or received medical treatment for 12 months prior to the effective date. For information on sharing for pre-membership conditions, see the section titled “Pre-Membership Medical Conditions.” Proration If shareable needs are ever significantly greater than shares available in any given month, ClearShare may prorate the needs amount requested for medical expenses. This involves an across-the-board percentage reduction of needs payments but does not necessarily mean that all member needs will not be met in that month. Shareable Amount The amount of the need request that remains after the member’s annual maximum has been satisfied and falls within the guidelines for sharing within the membership. Explanation of Sharing (EOS) Correspondence that is delivered to the participating members and their providers once medical needs have been processed, are pending, or have been rejected. The Sharing Summary will state their member responsibility amount as well as any amounts shared by the Benevolent Fund on the member’s behalf. Special Needs Medical needs that do not fall within the definition of eligible needs but are not a violation of the member requirements and may be eligible for Additional Giving (ie: a prior medical condition). Unusual, Customary, and Reasonable Costs (UCR) The general cost of medical services in a geographic area, as determined by ClearShare, based on what providers in the area usually charge for the same or a similar medical service. Unshareable Amount(s) A medical expense incurred by a member that is not shareable for one or more of the following reasons: a member’s violation of ClearShare’s Statement of Beliefs, non-current membership status, or any other condition or requirement that is excluded by the Member Guidelines. 30 Disclaimers All States Not Listed Below: NOTICE: ClearShare is not insurance or an insurance policy nor is it offered through an insurance company. Neither is ClearShare a discount healthcare program nor a discount health card program. Whether anyone chooses to assist you with your medical bills will be totally voluntary, as neither ClearShare nor any other member is liable for or may be compelled to make the payment of your medical bill. As such, ClearShare should never be considered as insurance. Whether you receive any amounts for medical expenses and whether or not ClearShare continues to operate, you are always personally responsible for the payment of your own medical bills. ClearShare is not subject to the regulatory requirements or consumer protections of your particular State’s Insurance Code or Statutes. Alabama Code § 22-6A-2 Notice: The organization facilitating the sharing of medical expenses is not an insurance company, and neither its guidelines nor plan of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant will be compelled by law to contribute toward your medical bills. As such, participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive any payment for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills. Alaska Stat. § 21.03.021(k) Notice: The organization coordinating the sharing of medical expenses is not an insurance company, and neither its guidelines nor plan of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant will be compelled by law to contribute toward your medical bills. Participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive a payment for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills. Arizona Rev. Stat. § 20-122(B)(7) Notice: The organization facilitating the sharing of medical expenses is not an insurance company and the ministry’s guidelines and plan of operation are not an insurance policy. Whether anyone chooses to assist you with your medical bills will be completely voluntary because participants are not compelled by law to contribute toward your medical bills. Therefore, participation in the ministry or a subscription to any of its documents should not be considered to be insurance. Regardless of whether you receive any payment for medical expenses or whether this ministry continues to operate, you are always personally responsible for the payment of your own medical bills. Arkansas Code Ann. § 23-60-104(b)(2)(G) Notice: The organization facilitating the sharing of medical expenses is not an insurance company and neither its guidelines nor plan of operation is an insurance policy. If anyone chooses to assist you with your medical bills, it will be totally voluntary because participants are not compelled by law to contribute toward your medical bills. Participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive a payment for medical expenses or if this organization continues to operate, you are always personally responsible for the payment of your own medical bills. 31 California A number of states, including California require residents to have qualifying health insurance, also called an individual mandate. Under California’s individual mandate, those who do not have qualifying health insurance coverage may face a financial penalty unless they qualify for an exemption. Because ClearShare is not insurance, a ClearShare membership does not qualify as health insurance coverage for California residents and therefore a ClearShare membership by itself does not meet the California individual mandate. But ClearShare can assist with health care costs that may not be covered by a qualifying health insurance plan. To get more information about qualifying health insurance coverage and details about the California individual mandate, visit Covered California’s website (CoveredCA.com) or the California Franchise Tax Board’s website (ftb.ca.gov). District of Columbia A number of states, including D.C. require residents to have qualifying health insurance, also called an individual mandate. Under D.C.’s individual mandate, those who do not have qualifying health insurance coverage may face a financial penalty unless they qualify for an exemption. Because ClearShare is not insurance, a ClearShare membership does not qualify as health insurance coverage for D.C. residents and therefore a ClearShare membership by itself does not meet the D.C. individual mandate. But ClearShare can assist with health care costs that may not be covered by a qualifying health insurance plan. To get more information about qualifying health insurance coverage and details about the D.C. individual mandate, visit https://disb.dc.gov/page/do-you-know-your-health-insurance-rights Florida Stat. § 624.1265(3) Notice: The organization facilitating the sharing of medical expenses is not an insurance company, and neither its guidelines nor its plan of operation is an insurance policy. Membership is not offered through an insurance company, and the organization is not subject to the regulatory requirements or consumer protections of the Florida Insurance Code. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant is compelled by law to contribute toward your medical bills. As such, participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive any payments for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills. Georgia Code Ann. § 33-1-20(a)(6) Notice: The organization facilitating the sharing of medical expenses is not an insurance company, and neither its guidelines nor plan of operation is an insurance policy. Whe

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