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summary of sharing

Guidelines Effective 05.01.2022

SHARING DETAILS

Annual Sharing Cap $500,000 per member per membership year.
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 annually.

CO-SHARE LIMIT There is a co-share limit of $5,000 per household per membership year.
FIRST 60 Days of Membership Limit Eligible expenses are limited to $50,000. Does not apply to newborns added within 30 days of birth.
Lifetime Sharing Limits for Smokers

Eligible expenses are limited to $ 50,000-lifetime max. (Stroke, cancer, heart conditions, and Chronic obstructive pulmonary disease-COPD).

Member Bill submission

If a member must submit a bill for processing, it must be submitted electronically using the Medical Expense Form available at www.impactHealthSharing.com/forms. We are no longer accepting bills via email.

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.

PRE-EXISTING CONDITIONS

Pre-Existing Medical Conditions are conditions in which signs, symptoms, testing, diagnosis, treatment, or use of medication occurred within 36 months prior to membership (based on medical records). 

A Pre-Existing Medical Condition is eligible for sharing after the condition has gone 36 consecutive months without signs, symptoms, testing, diagnosis, treatment, or use of medication (based on medical records).

Pre-notification
  • Cancer Treatment
  • Elective Cardiac Procedures
  • Inpatient/outpatient surgery (not in the doctor’s office)
  • Non-emergency hospital/facility admission
  • Organ/Tissue Transplant Services
  • Maternity

**Pre-notification of medical bills does not guarantee eligibility or sharing.

**If a member or their provider does not pre-notify Impact, the member is subject to an additional co-pay of $1,000 for the illness or event.

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

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. The PRA 12-month period begins on the 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. Members must pay 100% of the session consult fee at the time of service and must the necessary information to Impact for processing via the Medical Event Form.

 

Virtual Mental Health is considered a Specialist for provider fee purposes.

Wellness Visits/Screening Tests - Under the age of 6

Members under the age of 6 receive one annual visit shared at 100% by Impact’s Members.

Additional visits will follow routine well-child guidelines.

Includes a $150 allowance for the following routine labs as ordered by the provider during the annual/well visit.

  • 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/HPV
  • PSA

Routine Labs during annual well visit:

Vaccinations/Immunizations are NOT eligible for sharing.

Wellness Visits/Screening Tests – Age 6 and older

One annual/well visit is shared into at 100% by Impact’s Members, for those who are 6 years and older per membership year.

Includes $150 allowance for the following routine labs as ordered by provider during the visit.

  • 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/HPV one every 3 years, ages 21-65  
  • PSA one every year starting at age 45

Vaccinations/Immunizations are NOT eligible for sharing.

SHARING SPECIFICS

ABORTION

Not eligible for sharing.

Acupuncture Not eligible for sharing.
Allergy injections, serum and testing

$50 provider fee per test and per injection.

Subjected to 10% co-share once PRA has been met.
Alternative treatment Not eligible for sharing.
Ambulance (ground transfer) Subjected to 10% co-share once PRA has been met.
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

Subjected to 0% co-share once PRA has been met.

Limited to $500 per member per membership year.

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.

Hospice Care

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

Subject to a lifetime limit of $15,000 per member.

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.
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 Routine

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

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

Treatment-related to motorcycle accidents is limited to $100,000 per incident.

Naturopathic Treatment Not eligible for sharing.
Non-prescription drugs and medical supplies Not eligible for sharing.
Orthotics Not eligible for sharing.
Prostheses

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

Up to 2 max per lifetime for the same condition.

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

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

 

*No provider fee*

Combined limit of 50 visits per member per membership year.

Urgent Care

$75 provider fee +

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

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