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SHARING DETAILS

Annual Sharing Cap

There is an annual sharing cap of $500,000 per member per Membership

Co-Share

As an Impact member, after your PRA has been met, you pay 10% of all Eligible Medical Bills as a co-share.  The remaining 90% is Published for Sharing to the Impact membership.

There is a co-share limit of $5,000 per household per year. In other words, after a total of $5,000 in co-shares is paid by the member, they will not be subject to a co-share until the amount resets on their Membership Date.

Co-Share Limit

There is a co-share limit of $5,000 per household per membership year.

First 60 Days of Membership Limit

For the first 60 days of membership, members are eligible to have up to $50,000 of their Eligible Medical Bills shared (excluding pre-existing conditions).

Does not apply to newborns added within 30 days of birth. Maternity sharing is limited to $150,000 per single pregnancy event. Year. There is no lifetime limit on sharing.

Lifetime Sharing Limits for Smokers

Medical cost sharing for the needs of smokers and tobacco users 50 years of age and older is limited to $50,000 lifetime for each of the following four disease categories: 
•     Stroke III. D. Limited Sharing *Limited Sharing is subject to the PRA and co-share
•     Treatment for members age 65 or older that are not enrolled in Medicare The tobacco assessment does not apply to Seniors, but BMI assessment does.

Member Bill Submission

In the event that a member must submit a bill for processing, it must be submitted electronically using the Medical Expense Form at www.impactHealthSharing.com/forms.  

When submitting a Medical Expense Form (MEF), members are responsible for obtaining all information needed for processing. Only MEFs that contain all needed information will be accepted for processing.  

Outpatient Mental Health

$75 specialist provider fee & 10% co-share once PRA has been met. Eligible for sharing if performed by a qualified provider up to 5 visits per member per membership year. Outpatient Mental Health providers are considered Specialists for provider fee purposes and are subject to the PRA and co-share.

Pre-Existing Conditions

Pre-Existing Medical Conditions are conditions in which known signs, symptoms, testing, diagnosis, treatment, or use of medication occurred within 36 months prior to membership (based on medical records). A known sign is any abnormality indicative of disease, discovered on examination/diagnostic testing before joining membership.

A symptom is any subjective evidence of disease. In contrast, a sign is objective.
A Pre-Existing Medical Condition is eligible for sharing after the condition has gone 36 consecutive months without known signs, symptoms, testing, diagnosis, treatment, or medication (based on medical records).


If you have been diagnosed with cancer that is in complete remission, and you are only undergoing testing for surveillance purposes, then bills related to those services will not be eligible for sharing for the first 36 months of membership. If after 36 months you are without signs, symptoms, testing (other than
surveillance testing), diagnosis, or treatment (medication), medical expenses related to that cancer diagnosis will be eligible for sharing.

High blood pressure or high cholesterol that is controlled through medication will not be considered a Pre-Existing Medical Condition for purposes of determining eligibility for future vascular or cardiac events.


The Pre-Existing Medical Condition limitations do not apply to members 65 years old and older. Take our quick and easy quiz to understand your pre-existing conditions and their impact on your membership.

Pre-Eligibility

Pre-eligibility is required for any of the following treatments
to be eligible for sharing:
• Cancer Treatment
• Elective Cardiac Procedures
• Non-emergency inpatient/outpatient surgery
• Organ/Tissue Transplant Services
• Maternity
• Imaging: MRIs and Nuclear Imaging (i.e. PET scans)
3-5 business day notice required, expediated review
on a case-by-case basis. Medical records are required
to determine pre-eligibility and failure to provide requested records for review will result in the bill being ineligible for sharing.
Providers may request pre-eligibility online or by calling (855) 378-6777.

Prepayment When pre-payment is requested, Impact will make every effort to negotiate with the provider/facility to ensure that we obtain a rate that is consistent with our permitted sharing level (120-160% of the The Centers for Medicare & Medicaid Services [CMS] rate). If the provider/facility is unable to provide a rate that meets our permitted sharing level, Impact will make every effort to find a provider/facility whose fees are
closer to our permitted sharing level. The member can choose to see the provider of their choosing, but if the rate is more than our permitted sharing level, then prepayment and sharing will be limited to 200% of the CMS rate, and the member will be responsible for the remaining balance.


Any bills paid in full by the member will be shared based on what was paid.

Prescriptions

Present Member Card at the Pharmacy.

Prescription drugs are eligible for sharing when not related to a pre-existing condition and:

  • After $25 for generic.
  • After $50 on branded meds when generic is unavailable.
  • Rx must be purchased using the member ID.
  • Members pay 100% upfront at the pharmacy.
  • Psychotropic medications and birth control are not eligible for sharing.

Sharing max for Rx is $1200 per member per membership year after the PRA has been met

Primary Responsibility Amount (PRA)

$2,500

$5,000

$7,500

$10,000

**$1,000 for Impact Members over the age of 65

 

The Primary Responsibility Amount (PRA) is the dollar amount a Household must pay toward their own Eligible Medical Bills during a 12-month period before their Eligible Medical Bills can be published and shared by the membership.

All Eligible Medical Bills are subject to the annual PRA and co-share except the annual/well office visit and lab allowance as detailed in section III. D.

The PRA 12-month period begins on the Membership Date. The PRA resets on the anniversary of your Membership Date. Your Membership Date is the date that your membership in the Impact Sharing Plan started. A member can change their PRA amount on the anniversary of their Membership Date.

Provider Fees

At the time of receiving service from a medical care provider, members pay the following:

  • $0 for Telemedicine via Member Portal only
  • $50 for Primary Care
  • $50 for each Allergy Test/Serum Injection
  • $75 for Specialist/Urgent Care and Outpatient Surgical Facilities
  • $150 for Emergency Room or Inpatient Hospitalization

These fees are not applied to the PRA and are paid even if the member has met the PRA for the year.

Virtual Mental Health

Virtual Mental Health Care is eligible for sharing through a teletherapy provider approved by Impact (found in the Member Center).

Members must pay 100% of the session consult fee at the time of service and may submit proper receipts to Impact for processing via the Medical Expense Form. Virtual Mental Health is considered a Specialist for provider
fee purposes and subject to the PRA and co-share.

Wellness Visits/Screening Tests - Under the Age of 6

Members under the age of 6 receive one annual visit. Additional visits will follow routine well-child guidelines as dictated by the American Academy of Pediatrics. These additional visits are subjected to PRA and co-share. Well-child care is defined as recommended routine check-ups and associated lab work, excluding vaccinations and/or immunizations.

Wellness Visits/Screening Tests - Age 6 and older

Wellness Visits and Diagnostic tests are eligible for sharing as follows:

(Both the annual/well office visit and $150 lab allowance are 100% sharable and not subject to the PRA or co-share.)

  • One annual/well office visit for members 6 years and older per membership year, and includes $150 allowance to be used towards any of the labs listed below.
  • Complete Blood Count with Differential and Platelets
  • Comprehensive Metabolic Panel
  • Lipid Profile with Lipoprotein Particle Assessment
  • Hemoglobin A1C
  • Vitamin D-25 OH
  • C-Reactive Protein
  • Fecal Occult Blood Test
  • Pap Smear
  • PSA

Impact Health Sharing Membership Guidelines

Impact Health Sharing is NOT insurance and these Guidelines are not a contract for insurance. The Guidelines do, however, outline the way in which voluntary sharing of healthcare expenses occurs among members. To see the complete Guidelines click here.

SHARING SPECIFICS

Abortion

Not eligible for sharing.

Acupuncture

Not eligible for sharing.

Allergy Injections, Serum and Testing

$50 for each Allergy Test/Serum Injection

These fees are not applied to the PRA and are paid even if the member has met the PRA for the year. For eligible services, the Provider Fee is applied, then any remaining PRA and finally the Co-share is applied up to the Co-share limit.

Alternative treatment

Not eligible for sharing.

Ambulance (ground transfer)

Medical transportation to the nearest facility, including ground and air ambulance services to hospitals, is eligible in emergency situations or when medically necessary for transport for admission to another medical facility.

Air ambulance

Subjected to 10% co-share once PRA has been met.

Medical transportation to the nearest facility is eligible in emergency situations or when medically necessary for admission to another medical facility.

Air ambulance is limited to $25,000 lifetime max per member.

Ambulatory/outpatient surgical center expenses

Subjected to 10% co-share once PRA has been met.

Anesthesia Expenses

Subjected to 10% co-share once PRA has been met.

Assistant Surgeon/Surgeon Expense

Subjected to 10% co-share once PRA has been met.

Biofeedback

Not eligible for sharing

Chemotherapy/Radiation Expenses

Subjected to 10% co-share once PRA has been met.

Pre-notification required.

Colonoscopy - Diagnostic and Routine

Subjected to 10% co-share once PRA has been met.

Routine Colonoscopy 1 every 10 years starting at age 45 or one every 5 years for members at high risk.

Dental/Injury Trauma

Not eligible for sharing, unless related to an eligible medical injury or illness.

Durable Medical equipment

DME related to an eligible need is eligible for sharing for up to $500 per member per membership year toward the rental or purchase once the PRA has been met.

DME expenses are also subjected to PRA and co-share.

Emergency room visit

$150 provider fee. Subjected to 10% co-share once PRA has been met.

Experimental treatment

Not eligible for sharing.

Fertility/Infertility

Not eligible for sharing.

genetic Defects, Hereditary Disease, or Congenital Conditions

Treatment related to genetic defects, hereditary diseases, or congenital conditions present before membership is not eligible for sharing.

Fetal abnormalities and/or congenital abnormalities noted in medical records prior to the mother joining Impact Health Sharing, will be considered a pre-existing condition and would not be eligible for sharing.

Genetic Testing

Genetic testing is only shareable for an existing medical condition (that is not a pre-existing condition). Routine genetic testing is not eligible for sharing.

Hearing Aides

Not eligible for sharing.

Home healthcare

Skilled care at home services for an eligible need are limited to 40 visits per member per membership year by a registered ARNP, LPN, or RN. A visit is limited to a maximum block of 4 hours.

Subjected to 10% co-share once PRA has been met.

Hopsice Care

Hospice care services are eligible for sharing
when prescribed by a physician and is subject to  a lifetime limit of $15,000 per member once PRA has been met and subject to co-share.

Inpatient Hospital Expenses

$150 provider fee.

Subjected to 10% co-share once PRA has been met.

Inpatient Mental health/Substance Abuse

Not eligible for sharing.

Lab, X-ray, diagnostic imaging

Subjected to 10% co-share once PRA has been met.

Diagnostic tests are eligible for sharing as follows: (Both the annual/well office visit and $150 lab allowance are 100% sharable and not subject to the PRA or co-share.) See III.D 

maternity

Subjected to 10% co-share once PRA has been met.

  1. Eligible if mother has been a member for 12 months.
  2. Sharing is limited to $150,000 per single pregnancy event (not including baby’s bills).
Newborns

Can be added to the membership at birth and must be done within 30 days.

Fetal abnormalities and/or congenital abnormalities noted in medical records prior to the mother joining Impact Health Sharing, will be considered a pre-existing condition and would not be eligible for sharing.

Mammogram - Diagnostic and future

Subjected to 10% co-share once PRA has been met.

Routine mammogram 1 every year for ages 45-54 and one every 2 years for ages 55 and over

Medical Marijuana

Not eligible for sharing.

Motorcycle Accidents

Treatment is limited to $100,000
per incident once PRA has been met, subject to co-share. Sharing will be secondary to the vehicle insurance.

Treatment will not be shared if there is abuse of alcohol or legal drugs or the use of federally illegal drugs.

Naturopathic Treatment

Not eligible for sharing.

Non-Prescription drugs and medical supplies

Not eligible for sharing.

Orthotics

Not eligible for sharing.

Prostheses

Prostheses are eligible for sharing, up to two max per lifetime for the same condition once PRA is met, is also subject to co-share.

*Limited Sharing is subject to the PRA and co-share

Skilled Nursing Facility

Not eligible for sharing.

Sleep studies

Subjected to 10% co-share once PRA has been met.

Only if related to a specific disease or disorder.

specialist

Subjected to 10% co-share once PRA has been met.

$75 provider fee.

Substance Abuse

Not eligible for sharing.

Temporomandibular joint disorder (TMJ)

Subjected to 10% co-share once PRA has been met.

Therapy : Chiropractic Adjustment • Physical Therapy • Occupational Therapy• Speech Therapy• Cardiac Rehabilitation• Vision Therapy

Outpatient therapy is limited to 50 visits per member per membership year regardless of the type of outpatient therapy, provided it is included in the list below and (subject to PRA and co-share)
•  Chiropractic Adjustment
 • Physical Therapy
• Vision Therapy 
• Occupational Therapy 
• Speech Therapy 
• Respiratory Therapy 
• Cardiac Rehabilitation

Urgent care

$75 provider fee +

Subjected to 10% co-share once PRA has been met.

Vaccination/Immunizations

Not eligible for sharing.

Vision

Routine vision not eligible for sharing.

Medical conditions such as Glaucoma or Cataracts and services related to a medical injury or illness are sharable.

Weight management treatment or procedure

Not eligible for sharing.

STILL HAVE QUESTIONS?

Get directly in touch with us. We are happy to talk through your unique circumstances.  

 

Member Services

Monday - Friday 

9 AM - 6 PM ET 

(855) 378-6777

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