summary of sharing

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

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.

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

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.

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.

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.  

$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 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 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.

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

$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.

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 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.

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 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