Summary of Sharing

$2,500

$5,000

$7,500

$10,000

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

The Annual Household 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.

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 Program started. A member can change their PRA amount on the anniversary of their Membership Date.

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.

Co-Shares are not required for members 65 years and older.

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 tobacco users 50

years of age and older is limited to $50,000 lifetime for

each of the following four disease categories:

• Stroke
• Cancer
• Heart conditions
• Chronic obstructive pulmonary disease (COPD)

Members who use tobacco or vape regularly are required to pay a Tobacco Assessment of $50 per month. The Tobacco Assessment does not apply to the Senior (65+) program.

Members who do not disclose this information may be subject to membership termination if it is determined after membership date.

You will be notified during the application process before you join if you qualify for this additional amount.

In the event that a member must submit a bill for review, it must be submitted electronically using the Bill Submission Tool in your Member Center. Check out www.impactHealthSharing.com/forms.  

Members are responsible for gathering and providing all required information, as only complete submissions will be accepted for review and processing. Any costs incurred in obtaining necessary records or documentation are the responsibility of the Member.

Please see this article for more information on how to submit a bill with Impact.

Virtual Short-Term Teletherapy  is only eligible for sharing with the teletherapy provider approved by Impact (found in the Member Center). Beyond the set number of complimentary short-term visits allowed with membership, Members are responsible for paying 100% for additional visits upfront and must submit those expenses to be considered for sharing.  The provider fee for Virtual Short-Term Teletherapy is waived.

For a complete understanding of this member perk, click here. 

Outpatient Mental Health Care is eligible for sharing if performed by a qualified provider up to five visits per member, per membership year. Outpatient Mental Health providers are considered Specialists for provider fee purposes and subject to the annual PRA and co-share.

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)  not X-rays or ultrasounds 
3-5 business day notice required, expedited 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.

Prescription medication expenses for prescribed drugs that may be dispensed, injected, or administered may be credited toward the annual PRA if they are not considered treatment for a pre-existing condition.

Members pay 100% of the prescription amount at the pharmacy, and submit eligible expenses in the Member Center. Only the amount paid over $25 for generic and over $50 for brand name medications will be applied to the annual PRA. After the member’s annual PRA has been met, eligible prescriptions will be shared as follows:

• After the first $25 on generic drug prescription
• After the first $50 on brand name prescription when a generic is unavailable
• Prescription medications must be purchased using the member ID card (see Rx information on the card)
• Psychotropic medication and birth control expenses are not eligible for sharing
  
  

The shareable amount is limited to $1200 per member, per membership year after the annual PRA has been met.

Exceptions may be made in the case of medications for cancer and transplant recipients.

Note: Members 65 and older must have Medicare Part D for prescription costs to be eligible for sharing. All sharing will be secondary to Medicare.

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 known sign is any abnormality indicative of disease discovered on examination/diagnostic testing or known to the member before joining membership.

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.

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

• $0 (provider fee waived) for Virtual Telehealth
• $0 (provider fee waived) for Virtual Short-Term Teletherapy (See limitations in Section I.C.5)
• $0 (provider fee waived) for Outpatient Therapy (See limitations in Section I.C.5)
• $50 for Primary Care
• $50 for each Allergy Test/Serum Injection
• $75 for Specialist/Urgent Care
• $150 for Emergency Room or Inpatient Hospitalization.

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

Virtual Care  is shared on equal footing with all other medical expenses but the provider fee is waived at time of service. Virtual Care  is subject to all other limitations of health sharing costs and is not a promise to pay or provide that service by either Impact or its membership. As with all other medical costs and expenses, contribution to Virtual Care  remains voluntary.

Virtual telehealth visits are complimentary for members when conducted using Impact’s approved telehealth provider (found in the Member Center). The provider fee is waived at the time of service. Telehealth is subject to all other limitations of health sharing costs and is not a promise to pay or provide that service by either Impact or its membership. As with all other medical costs and expenses, contribution to Telehealth remains voluntary. Only telehealth visits initiated via the Member Center will be eligible for sharing.

Virtual Short-Term Teletherapy  is only eligible for sharing with the teletherapy provider approved by Impact (found in the Member Center). Beyond the set number of complimentary short-term visits allowed with membership, Members are responsible for paying 100% for additional visits upfront and must submit those expenses to be considered for sharing.  The provider fee for Virtual Short-Term Teletherapy is waived

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