HealthShares group medical expenses into two broad categories: eligible and ineligible. While eligible medical expenses are shared with members of the community, ineligible expenses are the member’s responsibility. Which medical expenses are considered ineligible can differ between HealthShares and between memberships of the same HealthShare. Expenses may be considered ineligible depending on the associated conditions, treatments, or services rendered, amount of money already shared, whether they are subject to co-sharing, and how long a member has been with the community, among other factors.
Some of the costs HealthShare members must pay for are described in more detail below.
Monthly contributions
Monthly contributions are the fees members pay in order to be part of the medical cost sharing community. These monthly contributions are used to share the medical expenses of the community, as well as pay for the HealthShare’s administrative costs. Because of this, if a member fails to pay their monthly contribution in a timely manner (usually 60 days after their billing date), their medical expenses will become ineligible for sharing.
Personal responsibility
Personal responsibility is the amount a member needs to pay toward an eligible medical need before it becomes eligible for sharing. Depending on the HealthShare, the personal responsibility may be known as the initial unshareable amount (IUA), member responsibility amount (MRA), or something similar, but the meaning will be the same.
Typically, the more expensive the membership, the lower the personal responsibility amount, and the sooner needs will be shareable with the community. While memberships with high personal responsibility amounts may appear affordable from the outset, they may be difficult to use. Depending on a member’s medical needs, a high personal responsibility amount could be more of a burden than paying a higher monthly contribution for a lower personal responsibility amount.
Additionally, personal responsibility amounts may be higher than the one officially advertised, and associated with a membership for certain medical needs. Maternity care, for instance, sometimes has a different personal responsibility amount that must be met before the maternity need will be eligible for sharing.
It is also important to note that some HealthShares will limit how many personal responsibilities a member will be made to pay in a given year, or for a given need. If many members are participating on the same membership, it may be punishing for them to each have to pay associated personal responsibility amounts for their various medical needs. Some HealthShares, like Zion HealthShare for example, limit their initial unshareable amounts to three per membership, while others will require members to continue to pay personal responsibility amounts, regardless of the quantity already incurred by their membership that calendar year.
Members need to weigh the monthly cost of a membership with the associated personal responsibility amount, and the HealthShare’s policy toward personal responsibility amount limits, to see which fits their budget while fulfilling the their healthcare needs.
Co-share
Some HealthShares offer membership options with co-sharing, which is a percentage of eligible medical expenses the member must pay even after their personal responsibility amount has been met. Typically, memberships with co-sharing have cheaper monthly contributions than those without, and for good reason: paying even 10% of eligible medical costs can raise healthcare costs significantly. While HealthShares often limit the amount of eligible medical costs members will have to pay when co-sharing, these limits are often in excess of $10,000, and may only apply per medical need, rather than per calendar year.
While co-share memberships may seem affordable, depending on a member’s medical circumstances, they may not be as good of a deal as they initially seem.
Costs beyond sharing limits
Not all sharing is unlimited. Even after meeting the personal responsibility amount, some HealthShares put caps, or sharing limits, on the amount that can be shared. These sharing limits come in a few forms: per incident, annual, and lifetime.
Per incident, or per need, limits are often placed on medical expenses related to certain conditions, medical services, or forms of treatment. Some common per incident limits are related to maternity and preventive care, as well as treatment for pre-existing conditions. Depending on the medical need in question, the per incident sharing limit may increase depending on how long a member has been with that HealthShare, especially when it pertains to pre-existing conditions.
Rather than applying to any specific medical need, annual limits apply to all sharing for a membership throughout the year. Any medical expenses that exceed the annual limit are no longer eligible for sharing, and will instead be the responsibility of the member. Once the year is over, the limit will reset, and the member will once again be able to share eligible medical expenses. Annual limits can differ between membership options offered by the same HealthShare, while some other HealthShares don’t have any annual limits on sharing.
Lastly, there are lifetime limits. Unlike annual limits, lifetime limits do not reset at the end of the year. Once a member’s sharing has exceeded their lifetime limit, they will no longer be able to share medical expenses with the community.
Ineligible medical expenses
In addition to the above, medical expenses related to certain medical conditions, treatments, and services are ineligible for sharing. These include elective procedures, like cosmetic surgery, as well as birth control, fertility treatments, and expenses related to pre-existing conditions during the first year (or more) of membership.
Whether it be for religious or ethical reasons, or to keep from having to raise monthly contribution amounts for them to be shareable, what each HealthShare considers ineligible for sharing differs between companies.
Conclusion
HealthShares can be an affordable, effective part of a healthcare plan. But HealthShare members should know what their community provides, and what it does not. Personal responsibility amounts, waiting periods, and sharing limits should all be serious considerations for current and prospective members alike.
