Datasets:

amogh-sinha
/

Llama-2-7B-Chat-GGML

Modalities:

Text

Formats:

Size:

Libraries:

Dataset card Viewer Files Files and versions Community

Dataset Viewer

Auto-converted to Parquet

Full Screen Viewer

Full Screen

Split (1)

train · 1 rows

text stringclasses 1 value
Program Sharing Details for the Healthy Life EasyShare Programs I. General Sharing Requirements, Restrictions, Limitations & Maximums Total eligible needs for sharing among the Members are limited as set forth in this section, or elsewhere in these Guidelines, and as may be indicated in writing to the individual Sharing Member from time-to- time.i.Waiting Period Prior to Sharing Eligibility.The following waiting periods apply before Medical Expense Needs may become eligible for sharing through this Universal HealthShare EasyShare Programs: 1.For a member who has been a Sharing Member continuously for at least twelve (12) months prior to conception, medical expenses for Maternity are eligible for sharing, subject to the applicable Annual Non-Sharable Medical Amount; 2.There is a 180-day waiting period before any Medical Expense Need for Cologuard testing may be eligible for sharing; 3.There is a 30-day waiting period before any Medical Expense Need for Preventive Care including an Annual Routine Physical or Well Child Exam may be eligible for sharing; and 4.There is a 90-day waiting period before any other Medical Expense Need may be eligible for sharing.Note: This 90-day waiting period does not apply to sharing eligibility for Telemedicine, Primary Care, Urgent Care, or Specialty Care visits or diagnostic testing, in-office procedures, and laceration repair that take place during the visit, however, the waiting period does apply to Imaging and office based surgical procedures.ii.Annual Non-Sharable Amounts for Medical Expenses.The EasyShare Programs have no annual Non-Sharable Amount; it is $0 for these Programs.iii.Consultation Fees.Members in the EasyShare Programs must always pay the following per-visit consultation fees, payment of which will be due at the time of your visit. This portion of your fees are never eligible for sharing; they are always your personal responsibility: Member Consultation Fee EasyShare50 EasyShare25 Telemedicine Consultation $0 $0 Primary Care Physician Visits $25 $40 Pediatrics Visits $25 $40 Routine Annual Physical/Well Child Exam and Preventive Care Visits (including Immunizations) $25 $40UHFR093021E100121 Page103 Specialty Physician Visits $50 $75 Urgent Care Physician Visits $75 $75 The EasyShare Programs allow for immediate sharing for Primary Care, Specialty Care, Pediatric, and Urgent Care office visit charges, (the 90-day waiting period does not apply to these office visits).Preventive Services have a 30 day wait period. You must pay a Consultation Fee for each visit; this fee will be due at the time of your visit. After your payment of the Consultation Fee, the remaining portion of the physician charges for the office visit only will be eligible under this sharing category. Charges other than the actual Office Visit fee billed for physician services from that visit, such as testing, screening, imaging, and procedures, may be sharable if applicable, subject to requirements and limitations. (If multiple visits are required for an immunization that is eligible for sharing, the Member Consultation Fee will apply to the initial visit and the cost of the immunization and the subsequent office visit to complete the immunization will all be eligible for sharing.) If imaging is done both without and with a contrast agent, that is considered two separate imaging series.Similarly, if imaging is done on two different body parts (e.g., head and leg), that is considered two separate imaging series.All outpatient CT Scan, MRI, and X-Ray imaging have a 90-day waiting period and sharing eligibility is limited to two such imaging services per year. These services are sharable only with a physician prescription and must be procured at a free standing in-network diagnostic center and not from a hospital unless received as an admitted patient. For eligible imaging services received other than from a hospital, EasyShare limits sharing to not more than $400 per imaging series for CT scans and MRIs and $250 per imaging series for x-rays with the member always responsible for any amount above that limit. Sharing is subject to the annual program limits of EasyShare inclusive of any other eligible, sharable medical expenses incurred throughout the Program Year.Sharing expenses for Ambulance or Emergency Room services are only intended for medical conditions that are life threatening or could seriously jeopardize the health of the individual and only when the injury or illness results in an in-patient hospital stay. If eligible, EasyShare limits sharing for eligible emergency services to not more than $1,000 per incident. All emergency and transportation-related expenses in excess of $1,000 are always the responsibility of the member.iv.Annual Sharing Limits.There is an annual limit on the total amount of medical expenses that may be shared for any individual Member in the EasyShare Program (“Annual Sharing Limit”) inclusive of any other eligible sharable medical expenses incurred throughout the Program Year. The Annual Sharing Limits that establish the maximum sharable amounts for any member in each EasyShare Program are as follows: Annual Combined Program Maximum Routine Annual Physical, Well Child Exam, and Preventive Care Combined Sharing Limit for Standard Programs EasyShare50 $50,000 $500 maximum, per member per year EasyShare25 $25,000 $500 maximum, per member per yearUHFR093021E100121 Page104 v.Lifetime Sharing Limits.The maximum amount of lifetime sharing available for any EasyShare50 member is $500,000 and the maximum amount of lifetime sharing available for any for EasyShare25 member is $250,000.vi.Per Medical Incident Sharing Limits.There is a limit on the total amount of medical expenses that may be shared for each Member in connection with any Medical Incident (as defined herein), inclusive of all inpatient and outpatient Facility and Professional expenses related to that Medical Incident.The per Medical Incident sharing limit applicable for the EasyShare50 Program is as follows: Service # of visits/incidents Eligible for Sharing Member Pays Inpatient Hospitalization 10 days Up to $3,000 per day for room and board Any charge above the sharable limit Inpatient and Outpatient Surgery 2 procedures per year Up to $3,000 per incident Any charge above the sharable limit Emergency Room 2 visits per year Up to $1,000 per incident Any charge above the sharable limit Ambulance 2 incidents per year Up to $500 per incident Any charge above the sharable limit CT Scan 2 imaging series per year Up to $400 per imaging series Any charge above the $400 per imaging series MRI 2 imaging series per year Up to $400 per imaging series Any charge above the $400 per imaging series X-Ray 2 imaging series per year Up to $250 per imaging series Any amount above $250 per imaging series The per Medical Incident sharing limit applicable for the EasyShare25 Program is as follows: Service # of visits/incidents Eligible for Sharing Member Pays Inpatient Hospitalization 10 days Up to $2,500 per day for room and board Any charge above the sharable limit Inpatient and Outpatient Surgery 2 procedures per year Up to $2,500 per incident Any charge above the sharable limit Emergency Room 2 visits per year Up to $1,000 per incident Any charge above the sharable limit Ambulance 2 incidents per year Up to $500 per incident Any charge above the sharable limit CT Scan 2 imaging series per year Up to $400 per imaging series Any charge above the $400 per imaging series MRI 2 imaging series per year Up to $400 per imaging series Any charge above the $400 per imaging seriesUHFR093021E100121 Page105 X-Ray 2 imaging series per year Up to $250 per imaging series Any amount above the $250 per imaging series The EasyShare Programs share the actual charges of Room and Board and procedures up to the maximum per-day or per-incident limit, inclusive of any other eligible, sharable medical expenses incurred that day.Emergency Room and Ambulance cost sharing for the EasyShare Programs are subject to the 90-day waiting period and are limited to a maximum of two incidents per year. Emergency Room and Ambulance expenses are only available for sharing for medical conditions that are life threatening or could seriously jeopardize the health of the individual by seriously impairing bodily functions or by causing serious dysfunction of any bodily organ or part, and if the illness results in an in-patient hospital stay.Inpatient and outpatient hospital and surgery have a 90-day waiting period for the EasyShare Programs.All outpatient CT Scan, MRI, and X-Ray imaging for the EasyShare Programs have a 90-day waiting period and are sharable for up to two imaging series per year in each category, and only with a physician’s prescription. Imaging services must be procured at a freestanding, in-network diagnostic center, unless received as an admitted patient or performed in connection with an outpatient or ambulatory surgical center procedure, in the same facility where the procedure is being performed, and on the same day as the procedure is performed.vii.Annual Visits & Hospitalization Sharing Limits Sharing is limited to a maximum number of visits/days/incidents per Program Year for each Member, as follows: Type of Visit or Therapy Session Max. Number of Visits/Days/Incidents Per Program Year Eligible for Sharing Annual Routine Physical or Well Child Exam 1 visit per Program Year Primary Care, combined with Pediatrics 4 visits in total for any combination of Primary Care and Pediatrics (Annual Physical or Well Child Exam does not count towards this limit) per Program Year Urgent Care 2 visits per Program Year Specialty Care 2 visits per Program Year Inpatient Hospital Care 10 days per Program Year Surgery (Inpatient or Outpatient) 2 procedures per Program Year Emergency Room 2 visits per Program Year Ambulance 2 incidents per Program Year CT Scan 2 visits/series per Program Year MRI 2 visits/series per Program Year X-Ray 2visits/series per Program Year For the EasyShare Programs, once the 90-day waiting period has passed, the following portions of Eligible Medical Expenses are generally sharable at the actual amount charged up to the maximum day or incident limit amounts inclusive of any other eligible, sharable medical expenses incurred throughout the Program Year based on the following schedule, subject to all exclusions, restrictions and limitations set forth in these Guidelines:UHFR093021E100121 Page106 Type of Medical Need EasyShare Per-incident Limit 1 Maximum Number of Days / Incidents 1 Type of Medical Need EasyShare50 Per-Incident Limit 1 EasyShare25 Per-Incident Limit 1 Maximum Number of Days / Incidents 1 Hospitalization Room & Board $3,000 $2,500 10 Inpatient or Outpatient Surgical Procedures $3,000 per surgical procedure $2,500 per surgical procedure Two Surgical Procedures per Program Year Emergency Room2 $1,000 $1,000 2 incidents per Program Year Ambulance 2 $500 $500 2 incidents per Program Year CT Scan 3 $400 $400 2 per Program Year MRI 3 $400 $400 2 per Program Year X-Ray – Non-Hospital Facility 3 $250 $250 2 per Program Year 1.EasyShare pays a maximum annual per member amount ($50,000 for EasyShare 50 and $25,000 for EasyShare25) for all services combined. The table above represents the amounts shared for particular incidents and any limitations specifically related to such incidents. The program shares the actual charges of room and board up to the maximum listed in the chart above per day. In addition, for surgical procedures, the program shares the actual charges up to a maximum amount listed above per incident. The member is responsible for any amounts above the EasyShare amounts. In services where the member is responsible for the consultation fee EasyShare shares the balance up to program maximums.2.Emergency room cost sharing and ambulance limited to a maximum of 2 incidents per year.Emergency room/ambulance are only available for sharing if the intended for treatment of medical conditions that are life threatening or could seriously jeopardize the health of the individual and if the illness results in an in-patient hospital stay, inclusive of any other eligible, sharable medical expenses incurred throughout the Program Year.3.All outpatient CT Scan, MRI, and X-Ray imaging have a 90-day waiting period and sharable only with a physician prescription and must be procured at a free standing in-network diagnostic center unless received as an admitted patient. For CT Scan, MRI, and X-Ray imaging in a non-hospital environment EasyShare limits sharing to not more than$400 for CT Scan and MRI and not more than$250 for X- Ray with the member responsible for any amount above that limit. These diagnostic procedures are fully sharable if performed during an eligible, sharable inpatient stay and for an inpatient surgical procedure.viii.Sharing Amounts/Percentages.Sharing Percentages are not applicable to the EasyShare Programs. Sharing amounts/limits are shown above in section V, subsection vii, Per Medical Incident Limits.II. Medical Expense Sharing Medical costs are shared on a per person per Medical Incident basis for illnesses or injuries incurring medical expenses after your Effective Date that were medically necessary and provided by or under the direction of licensed Physicians, Hospitals or other licensed medical Facilities, or approved Practitioners.A Medical Incident means a medically diagnosed condition and all medical treatment(s) received andUHFR093021E100121 Page107 medical expenses incurred relating to such diagnosis. All medical bills of any nature relating to the same diagnosis are part of the same Medical Incident. Medical expenses eligible for sharing include, but are not limited to, physician and hospital services, emergency medical care, medical testing, x-rays, emergency medical transportation and prescription medications provided by a Hospital during an admission, unless otherwise limited or excluded by these Guidelines. Total bills incurred for medical costs must exceed the Annual Non-Sharable Amount established for your Program to be eligible for sharing (See Section 5.02 for details). Medical expenses must be submitted for sharing in the manner and form specified by Universal HealthShare. This includes the standard industry billing forms (HCFA 1500 and/or UB 92) and relevant/required medical records.The following Sections are designed to allow you to quickly check, based on type of health care facility, provider, service, product, treatment or physical/medical condition, to confirm whether a particular medical expense is generally sharable. Members share costs as addressed below, subject to both your prior payment of the applicable Annual Non-Sharable Medical Amount and all exclusions, restrictions and limitations set forth in these Guidelines. Any services not specifically referenced herein as either eligible or ineligible for sharing must be submitted to Universal HealthShare in advance for consideration and receive prior confirmation of general sharability to be eligible for sharing.i.Sharing for Facilities, Providers & Services Members generally share costs for the following health care facilities, providers, and services, as specifically described below. Note: All applicable Sharing Guidelines terms and limits of your sharing program, including the requirement for you to use an in-network provider and meet your Non-Sharable Amount apply.(a) Annual Routine Physical Exam.An Annual Routine Physical or Well Child Exam is sharable.(b) Ambulance.Emergency land or air ambulance transportation to the nearest medical facility capable of providing care that is medically necessary for a medical condition with symptoms of sufficient severity that the absence of immediate medical attention would reasonably be expected to result in death or serious jeopardy to the health of the individual (or, with respect to a pregnant woman, the woman’s unborn child) involving serious impairment to bodily functions or serious dysfunction of any bodily organ or part; provided, however, that air ambulance transportation is not sharable in situations where the use of a less expensive form of emergency transport could have been employed without materially increasing the risk of seriously jeopardizing your life or long-term health.(c) Audiological Procedures.N/A (d) Audiological Therapy.N/A (e) Chiropractic Therapy.N/A (f) Cologuard.After a 180-day waiting period, a Cologuard® noninvasive colon cancer screening test prescribed by a Physician may be sharable once every three (3) years for Members who are 45 or older, up to $650 perUHFR093021E100121 Page108 test for each Member, and the combined Preventive Care sharing limit will not apply to sharing for such tests.(g) Colonoscopy.A diagnostic colonoscopy is sharable when prescribed due to symptoms for a condition not evident prior to your membership. Routine or screening colonoscopies are not sharable.(h) Cosmetic Surgery.Cosmetic Surgery, including breast reduction or enhancement operations and any other elective cosmetic surgery or procedures done primarily to alter appearance or for any other non-health reasons, is not sharable.(i) CT Scan.For CT Scans in a non-hospital environment EasyShare limits sharing to a fixed amount of $400 per visit/series with the member responsible for any amount above that limit. All outpatient CT scan imaging have a 90-day waiting period, are sharable only with a physician prescription and must be procured at a free standing in-network diagnostic center unless received as an admitted patient.(j) Diagnostic Imaging See individual entries for CT scan, Mammogram, MRI, X-Ray imaging.(k) Emergency Room.Emergency room services provided on an outpatient basis at a Hospital, Clinic or Urgent Care Facility for stabilization or initiation of treatment of an Emergency medical condition, including when Hospital Admission occurs within 23 hours of emergency room treatment. EasyShare limits sharing to a fixed amount of $1,000 per visit and is only intended for Emergency treatment. Emergency room cost sharing is only intended for Emergency treatment, and Emergency Room expenses incurred for a non- Emergency situation will not be shared; provided, however, that for children six years and under any Emergency Room expenses will be presumed to be incurred for an Emergent Situation unless there is a compelling reason to conclude otherwise.(l) Hearing Surgery.N/A (m) Hearing Therapy.See Audiological Therapy.(n) Home Health Care.N/A (o) Hospice Care.N/A (p) Hospital Charges.Daily room and board charges up to a maximum of $2,500 per day for EasyShare 25 or $3,000 per day for EasyShare 50 for a maximum of 10 days annually for Inpatient hospital care or procedure for a medically diagnosed condition, but only when such care or procedure cannot be provided or performed on an outpatient basis or in a non-hospital, ambulatory facility. A separate sharable amount for an individual surgical procedure is available for up to $2,500 per procedure for EasyShare 25 or $3,000 perUHFR093021E100121 Page109 procedure for EasyShare 50 for up to two surgical procedures per program year. There is a 90-day waiting period before Hospital and surgical charges can be eligible for sharing.(q) Hyperbaric Oxygen Therapy.N/A (r) Infusion Therapy.N/A (s) Mammograms.Mammograms may be eligible for sharing once every two years for Members up to and including age forty-nine (49), and once every year for Members fifty (50) years of age and older, after the applicable waiting period. Only charges for conventional 2-D screening mammograms can be shared, not 3-D or other similar types of mammograms.(t) MRIs.For MRIs in a non-hospital environment EasyShare limits sharing to a fixed amount of $400 per visit/series with the member responsible for any amount above that limit. All outpatient MRI imaging have a 90-day waiting period, are sharable only with a physician prescription and must be procured at a free standing in-network diagnostic center unless received as an admitted patient.(u) Naturopathic and/or Alternative Treatments.N/A (v) Occupational Therapy.N/A (w) Organ Transplant.Expenses incurred in connection with any organ or tissue transplant are treated like any other hospitalization and surgical procedure and are subject to the same sharing limitations.(x) Physical Therapy.N/A (y) Physician Services.The EasyShare Program allows for immediate sharing for Primary Care, Specialty Care, Pediatric, and Urgent Care office visit physicians charges, as well as Preventive Services (the 90-day waiting period does not apply to these office visits). You must pay a Consultation Fee for each visit; this fee will be due at the time of your visit. After your payment of the Consultation Fee, the remaining portion of the physician charges for the office visit only will be eligible under this sharing category. Charges other than the actual Office Visit fee billed for physician services from that visit, such as testing, screening, imaging, and procedures, may be sharable if applicable, subject to requirements and limitations. (If multiple visits are required for an immunization that is eligible for sharing, the Member Consultation Fee will apply to the initial visit and the cost of the immunization and the subsequent office visit to complete the immunization will all be eligible for sharing.) If imaging is done both without and with a contrast agent, that is considered two separate imaging series and the Member Consultation Fee must be paid for both. Similarly, if imaging is done on two different body parts (e.g., head and leg), that is considered two separate imaging series and the Member Consultation Fee must be paid for both.UHFR093021E100121 Page110 (z) Plastic Surgery for Disfiguration.Medical care and treatment provided for disfiguration caused by amputation, mastectomy, disease or accident, including reconstructive mammoplasty or similar procedure performed by a general surgeon, is eligible for sharing. Any other plastic surgery or cosmetic care or treatment is ineligible for sharing, including but not limited to, pharmacological regimens; nutritional procedures or treatments; cosmetic surgery; salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal or revision of scars, tattoos or actinic changes.(aa) Prescription Drugs.The RxSimpleShare Prescription Drug Program is included in the Healthy Life EasyShare Programs.RxSimpleShare allows for the purchase of many common prescriptions for a $5 co-share. See section IX for details. Other prescription drugs are only eligible for sharing when provided by a Hospital as part of inpatient treatment or provided by a Facility during an outpatient surgical procedure.: (ab) PSA Test.PSA tests are eligible for sharing once every two years up to and including age forty-nine (49). PSA tests are eligible for sharing for members fifty (50) years of age and older once each year.(ac) Respiratory Therapy.N/A (ad) Speech Therapy/Speech Pathology.N/A (ae) Vision Therapy.N/A (af) Well Baby Visits.Well baby visits, including immunizations, are eligible for sharing within the first year of birth.(ag) Well Child Exam.See Annual Routine Physical Exam, above.(ah) X-Ray.For X-Rays in a non-hospital environment EasyShare limits sharing to a fixed amount of $250 per visit/series with the member responsible for any amount above that limit. All outpatient X-Ray imaging have a 90-day waiting period, are sharable only with a physician prescription and must be procured at a free standing in-network diagnostic center unless received as an admitted patient.ii.Sharing for Physical Conditions; Illnesses and Injuries.Expenses for most types of physical conditions resulting from Illness or Injury are generally sharable, subject to all applicable conditions and limitations set forth elsewhere in these Guidelines, although special provisions apply for certain conditions, as explained below: (a) Abortion in Specific Circumstances.Services, supplies, care or treatment in connection with an abortion may only be sharable if (a) the physical life of the mother is endangered by the continued Pregnancy and treatment via a cesarean section has been determined by a neonatologist to be inadvisable, or (b) the Pregnancy was the result of a rape or incest for which a police report was filed.UHFR093021E100121 Page 111 (b) Asthma.Asthma is generally sharable, but during the first 36 months membership, a Confirmation of No Prior Existence of Condition statement may be required.(c) Back Problems.Back problems are generally sharable, but during the first 36 months membership, a Confirmation of No Prior Existence of Condition statement may be required.(d) Bunions.Bunions are generally sharable, but during the first 36 months membership, a Confirmation of No Prior Existence of Condition statement may be required.(e) Cancer.Generally sharable, but limitations may apply if it is related to cancer of a type you had prior to becoming a Member (see Section 4.05(n)) and during the first 60 months membership, a Confirmation of No Prior Existence of Condition statement may be required.(f) Carpal Tunnel Syndrome.Carpal Tunnel Syndrome is generally sharable, but during the first 36 months membership, a Confirmation of No Prior Existence of Condition statement may be required.(g) Complications Arising from Maternity.Medical expenses for complications to the member are considered part of the maternity need.(h) Complications Arising from Sharable Medical Procedures.If complications arise from a medical procedure that is sharable, expenses for treating the complications are sharable unless the complication itself is not sharable under these Guidelines.(i) Dental Injury.Expenses for dental care are generally not sharable, with the following exceptions: i.Expenses for the treatment of natural teeth and caps (but not dentures or partial plates) that are broken/injured in an accident (but not an accident that occurs in the course of receiving dental care, when eating, or in certain motor vehicle accidents).ii.We do not share routine dental work such as (but not limited to): check-ups, cleanings (including deep cleanings), fillings, crowns, root canals, implants, removal of wisdom or infected teeth, dentures, bridges, anesthesia for routine dental care, or treatment of periodontal disease, except when these routine treatments are necessarily a part of surgery on the bones or other non-routine treatments. So, for example, if you have an infected tooth removed, that will normally not be sharable. But if the infection went into the jawbone and required removal of some of the bone, then the entire procedure would be sharable. Implants are not included because they always involve “surgery on the bone,” and there are usually less expensive alternatives.(j) Diabetes Diabetes is sharable, unless it is related to diabetes you had prior to becoming a member and it does not come within the exception described in Section VII.C.2. During the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.(k) Foot Disorders.Foot Disorders are generally sharable, but during the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.UHFR093021E100121 Page112 (l) Genetic Defects.Genetic Defects are sharable when at least one of the following is true: i.Neither the condition nor a symptom of the condition was discovered until after the then-current and continuously maintained membership had begun; ii.The condition has not required treatment or produced harmful symptoms, and has not deteriorated for at least five years; iii.The condition exists in a person who has been included in a membership from birth, and the member was included in a membership prior to the pregnancy; or iv.If the condition exists in a person who was adopted, the person has been included in a membership since the adoption, and the adopting parents were unaware of the condition at the time the adoption was finalized.(m) Heart Conditions.Heart Conditions are sharable unless related to a heart condition you had prior to becoming a member, and it does not come within the exceptions described in Section VII. During the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.(n) Hemorrhoids.Hemorrhoids are generally sharable, but during the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.(o) Hereditary Diseases.Hereditary Diseases are sharable under the same conditions as Genetic Defects.(p) Hernia.A Hernia is generally sharable, but during the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.(q) High Blood Pressure.As long as you have not been treated in a hospital for high blood pressure in the past four years, and you have been able to effectively and continuously control this condition through medication or diet, an incident that begins after your membership begins is sharable.(r) Pregnancy/Maternity.For a member who has been a Sharing Member continuously for at least twelve (12) months prior to conception, medical expenses for Maternity are eligible for sharing, subject to the applicable Annual Non- Sharable Medical Amount, as follows: i.Up to $5,000 per-pregnancy limit for a normal delivery or a cesarean section that is not medically necessary (whether for a single or multiple birth pregnancy), including but not limited to charges and expenses arising from physician care, hospital or birthing center admissions, attendance by midwives, or home deliveries accompanied by a midwife or physician.ii.Up to $8,000 per-pregnancy for Maternity ending in a delivery by cesarean section that is medically necessary because of complications that arise at the time of delivery (whether for a single or multiple birth pregnancy).iii.Up to $50,000 or the Program’s Annual Sharing Limit per pregnancy for Maternity ending in a natural delivery or cesarean section, for combined expenses for the member and newborn arising from complications at the time of delivery that threaten the life of the member or infant andUHFR093021E100121 Page113 requiring care or services not normally rendered at the time of delivery (whether for a single or multiple birth pregnancy).iv.In the case of an ectopic pregnancy diagnosed before a rupture, expenses eligible for sharing include costs of pre-operative tests, consultations and other expenses for keeping the member under medical care while determining what care should be offered for the Member and Child. In the case of an ectopic pregnancy that results in a ruptured fallopian tube, expenses eligible for sharing include surgery, post-operative recovery of the member, follow-up care, and treatment of any complications.In the case of an ectopic pregnancy, expenses eligible for sharing will be subject to the applicable per- Medical Incident limit, inclusive of costs of pre-operative tests, consultations and other expenses for keeping the member under medical care while determining what care should be offered and, in the case of an ectopic pregnancy that results in a ruptured fallopian tube, surgery, post-operative recovery of the member, follow-up care, and treatment of any complications.(s) Pre-Natal Care Visits.Visits for standard pre-natal care are generally sharable, subject to applicable visit limits.(t) Prostate Conditions.Prostate Conditions are generally sharable, but during the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.(u) Sexually Transmitted Diseases (STDs).HIV, AIDS, or other STDs contracted due to the actions of others (e.g., blood transfusions or medical procedures) will be shared. We do not share needs for sexually transmitted diseases, including the HIV virus and/or AIDS, when contracted through irresponsible behavior such as sharing hypodermic needles for legal or illegal drugs. It is the member’s responsibility to explain how the disease was contracted.(v) Sleep Apnea.Sleep Apnea is generally sharable, but during the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.iii.Medical Expenses Sharable Under Limited Circumstances.1.Injuries Caused by Motor Vehicle Accidents.Most needs for motor vehicle related injuries are generally shared, but there are exceptions that are described below. For purposes of these Guidelines, any vehicle with a motor or engine that is used for transportation, work, or recreation is a “Motor Vehicle,” any person driving, riding or otherwise controlling a Motor Vehicle is the “Operator,” and any person other than the Operator riding in, on or being pulled by a Motor Vehicle is a “Passenger.” Before any medical expenses for Motor Vehicle related injuries will be considered for sharing, they must first be submitted to any party that is responsible for the accident or liable for damages resulting from the accident.2.Accidents where you are not an Operator or Passenger.Needs for injuries caused by or incurred in a Motor Vehicle accident where you were not an operator or passenger (e.g., you were a bystander, pedestrian, bicyclist, etc., when injured) are sharable, but only to the extent the costs at issue are not the responsibility of any insurance carrier or liable party.3.Accidents where you are an Operator or Passenger.Needs for injuries caused by or incurred in a Motor Vehicle accident in which you were an operator or passenger of an on-road or off-road Motor Vehicles (including cars, trucks, motorcycles, tractors, farmUHFR093021E100121 Page 114 implements, construction equipment, go-karts, four-wheel or six-wheel ATVs, golf carts, personal moving devices, and all types of motorized watercraft and aircraft) will be sharable, to the extent the costs at issue are not the responsibility of any insurance carrier or liable party, but only if: (a) the Operator(s)/rider(s) were driving, riding or operating the vehicle off-road or on a public roadway that permits Motor Vehicles of the type involved in the accident; (b) the Operator and Motor Vehicle were validly insured as required by law; (b) the Operator(s)/rider(s) and Motor Vehicle were not engaged in racing or stunt competition and were not operating the Motor Vehicle recklessly; and (c) the Operator(s)/rider(s) were not operating the Motor Vehicle under the influence of alcohol, any recreational drug, any prescription drugs that bear a warning against operating a Motor Vehicle or heavy machinery, or any illegal substance as defined by applicable law.4.Accidents involving three-wheel vehicles or snowmobiles where you are an Operator or Passenger.Expenses from injuries related to accidents involving three-wheel vehicles or snowmobiles in which you were an operator or passenger are not sharable, whether off-road or on-road, even if local law allows three-wheel vehicles or snowmobiles to travel on public roads.5.Occupational or Work-Related Injuries.Expenses arising from the care and treatment of an Illness or Injury that is occupational, or that arises from work for wage or profit, including self-employment, are generally not eligible for sharing. However, provided such Illness or Injury results from legal employment, they will be considered for sharing if: a) The State in which the injuries occurred has no Worker’s Compensation laws or insurance requirements; or b) The State laws proscribing participation in the Worker’s Compensation system of that State do not allow the business owner and/or enterprise from participating in Workers Compensation. Documentation of such exemption may be required.iv.Conditional Member Expenses.Members with certain pre-existing conditions that are responsive to lifestyle changes may be accepted into the membership based on a mutually agreed upon treatment plan between the Conditional Member and Universal HealthShare. Conditional Members are assigned a health coach to monitor and encourage personal progress toward health goals. Health coaching sessions and related costs, including administrative fees charged by Universal HealthShare in its reasonable discretion, shall be paid for by the Conditional Member by remitting a monthly amount set, and revised from time to time, by Universal HealthShare. Certain expenses associated with that customized treatment plan may be eligible for sharing based upon review and case by case determination by Universal HealthShare, to include, but not be limited to, smoking cessation, weight loss or dietary control, diabetic testing supplies, or other program costs that may be eligible for sharing as an incentive to lifestyle change. The normal pre-existing condition guidelines may be altered at the discretion of Universal HealthShare to encourage participation in the Conditional Membership program as conducted, revised and implemented by Universal HealthShare.UHFR093021E100121 Page 115 III. Out-of-Network Physician Charges are Not Sharable If medical charges are incurred from providers and/or facilities that are out of network, the following guidelines will be used to determine sharable amounts for those charges. (You can always determine in advance whether a provider is out of network by asking your physician or hospital, or by contacting your Customer Service team.) Out-of-network physician services are not eligible for sharing except for emergency room visits, charges that are part of sharable inpatient hospitalization and surgery, or sharable outpatient surgical procedures.If eligible, these charges will be sharable at a percentage of the Medicare payable amount. Ask your provider or call your Customer Service team for details.IV. Sharing for Pre-Existing Conditions All rules related to Pre-Existing Conditions referenced in the Guidelines apply to the UHS Healthy Life EasyShare Programs, subject to the following exception: Conditions that exist at the time of enrollment that have evidenced symptoms and/or received treatment and/or medication within the 36 months prior to enrollment are not eligible for sharing during the first to years of Membership, except where specifically noted within these Sharing Guidelines. After the first two full years of continuous monthly membership, medical expenses incurred for a pre-existing condition are eligible for sharing up to the annual program limits inclusive of any other eligible, sharable medical expenses incurred throughout the Program Year, as if the condition was not pre-existing. For certain conditions listed in Article VI, Section 6.02, a statement signed by both the member and the doctor must be submitted, verifying that the condition did not exist prior to membership, or that the member went at least 36 and in some cases 48 months (up to 60 months for some conditions, such as cancer) without symptoms, treatment and medication subsequent to the time the condition last occurred or existed occurred prior to the individual becoming a member (“Confirmation of No Prior Existence”).

text

stringclasses

1 value

Program Sharing Details for the Healthy Life EasyShare Programs I. General Sharing Requirements, Restrictions, Limitations & Maximums Total eligible needs for sharing among the Members are limited as set forth in this section, or elsewhere in these Guidelines, and as may be indicated in writing to the individual Sharing Member from time-to- time.i.Waiting Period Prior to Sharing Eligibility.The following waiting periods apply before Medical Expense Needs may become eligible for sharing through this Universal HealthShare EasyShare Programs: 1.For a member who has been a Sharing Member continuously for at least twelve (12) months prior to conception, medical expenses for Maternity are eligible for sharing, subject to the applicable Annual Non-Sharable Medical Amount; 2.There is a 180-day waiting period before any Medical Expense Need for Cologuard testing may be eligible for sharing; 3.There is a 30-day waiting period before any Medical Expense Need for Preventive Care including an Annual Routine Physical or Well Child Exam may be eligible for sharing; and 4.There is a 90-day waiting period before any other Medical Expense Need may be eligible for sharing.Note: This 90-day waiting period does not apply to sharing eligibility for Telemedicine, Primary Care, Urgent Care, or Specialty Care visits or diagnostic testing, in-office procedures, and laceration repair that take place during the visit, however, the waiting period does apply to Imaging and office based surgical procedures.ii.Annual Non-Sharable Amounts for Medical Expenses.The EasyShare Programs have no annual Non-Sharable Amount; it is $0 for these Programs.iii.Consultation Fees.Members in the EasyShare Programs must always pay the following per-visit consultation fees, payment of which will be due at the time of your visit. This portion of your fees are never eligible for sharing; they are always your personal responsibility: Member Consultation Fee EasyShare50 EasyShare25 Telemedicine Consultation $0 $0 Primary Care Physician Visits $25 $40 Pediatrics Visits $25 $40 Routine Annual Physical/Well Child Exam and Preventive Care Visits (including Immunizations) $25 $40UHFR093021E100121 Page103 Specialty Physician Visits $50 $75 Urgent Care Physician Visits $75 $75 The EasyShare Programs allow for immediate sharing for Primary Care, Specialty Care, Pediatric, and Urgent Care office visit charges, (the 90-day waiting period does not apply to these office visits).Preventive Services have a 30 day wait period. You must pay a Consultation Fee for each visit; this fee will be due at the time of your visit. After your payment of the Consultation Fee, the remaining portion of the physician charges for the office visit only will be eligible under this sharing category. Charges other than the actual Office Visit fee billed for physician services from that visit, such as testing, screening, imaging, and procedures, may be sharable if applicable, subject to requirements and limitations. (If multiple visits are required for an immunization that is eligible for sharing, the Member Consultation Fee will apply to the initial visit and the cost of the immunization and the subsequent office visit to complete the immunization will all be eligible for sharing.) If imaging is done both without and with a contrast agent, that is considered two separate imaging series.Similarly, if imaging is done on two different body parts (e.g., head and leg), that is considered two separate imaging series.All outpatient CT Scan, MRI, and X-Ray imaging have a 90-day waiting period and sharing eligibility is limited to two such imaging services per year. These services are sharable only with a physician prescription and must be procured at a free standing in-network diagnostic center and not from a hospital unless received as an admitted patient. For eligible imaging services received other than from a hospital, EasyShare limits sharing to not more than $400 per imaging series for CT scans and MRIs and $250 per imaging series for x-rays with the member always responsible for any amount above that limit. Sharing is subject to the annual program limits of EasyShare inclusive of any other eligible, sharable medical expenses incurred throughout the Program Year.Sharing expenses for Ambulance or Emergency Room services are only intended for medical conditions that are life threatening or could seriously jeopardize the health of the individual and only when the injury or illness results in an in-patient hospital stay. If eligible, EasyShare limits sharing for eligible emergency services to not more than $1,000 per incident. All emergency and transportation-related expenses in excess of $1,000 are always the responsibility of the member.iv.Annual Sharing Limits.There is an annual limit on the total amount of medical expenses that may be shared for any individual Member in the EasyShare Program (“Annual Sharing Limit”) inclusive of any other eligible sharable medical expenses incurred throughout the Program Year. The Annual Sharing Limits that establish the maximum sharable amounts for any member in each EasyShare Program are as follows: Annual Combined Program Maximum Routine Annual Physical, Well Child Exam, and Preventive Care Combined Sharing Limit for Standard Programs EasyShare50 $50,000 $500 maximum, per member per year EasyShare25 $25,000 $500 maximum, per member per yearUHFR093021E100121 Page104 v.Lifetime Sharing Limits.The maximum amount of lifetime sharing available for any EasyShare50 member is $500,000 and the maximum amount of lifetime sharing available for any for EasyShare25 member is $250,000.vi.Per Medical Incident Sharing Limits.There is a limit on the total amount of medical expenses that may be shared for each Member in connection with any Medical Incident (as defined herein), inclusive of all inpatient and outpatient Facility and Professional expenses related to that Medical Incident.The per Medical Incident sharing limit applicable for the EasyShare50 Program is as follows: Service # of visits/incidents Eligible for Sharing Member Pays Inpatient Hospitalization 10 days Up to $3,000 per day for room and board Any charge above the sharable limit Inpatient and Outpatient Surgery 2 procedures per year Up to $3,000 per incident Any charge above the sharable limit Emergency Room 2 visits per year Up to $1,000 per incident Any charge above the sharable limit Ambulance 2 incidents per year Up to $500 per incident Any charge above the sharable limit CT Scan 2 imaging series per year Up to $400 per imaging series Any charge above the $400 per imaging series MRI 2 imaging series per year Up to $400 per imaging series Any charge above the $400 per imaging series X-Ray 2 imaging series per year Up to $250 per imaging series Any amount above $250 per imaging series The per Medical Incident sharing limit applicable for the EasyShare25 Program is as follows: Service # of visits/incidents Eligible for Sharing Member Pays Inpatient Hospitalization 10 days Up to $2,500 per day for room and board Any charge above the sharable limit Inpatient and Outpatient Surgery 2 procedures per year Up to $2,500 per incident Any charge above the sharable limit Emergency Room 2 visits per year Up to $1,000 per incident Any charge above the sharable limit Ambulance 2 incidents per year Up to $500 per incident Any charge above the sharable limit CT Scan 2 imaging series per year Up to $400 per imaging series Any charge above the $400 per imaging series MRI 2 imaging series per year Up to $400 per imaging series Any charge above the $400 per imaging seriesUHFR093021E100121 Page105 X-Ray 2 imaging series per year Up to $250 per imaging series Any amount above the $250 per imaging series The EasyShare Programs share the actual charges of Room and Board and procedures up to the maximum per-day or per-incident limit, inclusive of any other eligible, sharable medical expenses incurred that day.Emergency Room and Ambulance cost sharing for the EasyShare Programs are subject to the 90-day waiting period and are limited to a maximum of two incidents per year. Emergency Room and Ambulance expenses are only available for sharing for medical conditions that are life threatening or could seriously jeopardize the health of the individual by seriously impairing bodily functions or by causing serious dysfunction of any bodily organ or part, and if the illness results in an in-patient hospital stay.Inpatient and outpatient hospital and surgery have a 90-day waiting period for the EasyShare Programs.All outpatient CT Scan, MRI, and X-Ray imaging for the EasyShare Programs have a 90-day waiting period and are sharable for up to two imaging series per year in each category, and only with a physician’s prescription. Imaging services must be procured at a freestanding, in-network diagnostic center, unless received as an admitted patient or performed in connection with an outpatient or ambulatory surgical center procedure, in the same facility where the procedure is being performed, and on the same day as the procedure is performed.vii.Annual Visits & Hospitalization Sharing Limits Sharing is limited to a maximum number of visits/days/incidents per Program Year for each Member, as follows: Type of Visit or Therapy Session Max. Number of Visits/Days/Incidents Per Program Year Eligible for Sharing Annual Routine Physical or Well Child Exam 1 visit per Program Year Primary Care, combined with Pediatrics 4 visits in total for any combination of Primary Care and Pediatrics (Annual Physical or Well Child Exam does not count towards this limit) per Program Year Urgent Care 2 visits per Program Year Specialty Care 2 visits per Program Year Inpatient Hospital Care 10 days per Program Year Surgery (Inpatient or Outpatient) 2 procedures per Program Year Emergency Room 2 visits per Program Year Ambulance 2 incidents per Program Year CT Scan 2 visits/series per Program Year MRI 2 visits/series per Program Year X-Ray 2visits/series per Program Year For the EasyShare Programs, once the 90-day waiting period has passed, the following portions of Eligible Medical Expenses are generally sharable at the actual amount charged up to the maximum day or incident limit amounts inclusive of any other eligible, sharable medical expenses incurred throughout the Program Year based on the following schedule, subject to all exclusions, restrictions and limitations set forth in these Guidelines:UHFR093021E100121 Page106 Type of Medical Need EasyShare Per-incident Limit 1 Maximum Number of Days / Incidents 1 Type of Medical Need EasyShare50 Per-Incident Limit 1 EasyShare25 Per-Incident Limit 1 Maximum Number of Days / Incidents 1 Hospitalization Room & Board $3,000 $2,500 10 Inpatient or Outpatient Surgical Procedures $3,000 per surgical procedure $2,500 per surgical procedure Two Surgical Procedures per Program Year Emergency Room2 $1,000 $1,000 2 incidents per Program Year Ambulance 2 $500 $500 2 incidents per Program Year CT Scan 3 $400 $400 2 per Program Year MRI 3 $400 $400 2 per Program Year X-Ray – Non-Hospital Facility 3 $250 $250 2 per Program Year 1.EasyShare pays a maximum annual per member amount ($50,000 for EasyShare 50 and $25,000 for EasyShare25) for all services combined. The table above represents the amounts shared for particular incidents and any limitations specifically related to such incidents. The program shares the actual charges of room and board up to the maximum listed in the chart above per day. In addition, for surgical procedures, the program shares the actual charges up to a maximum amount listed above per incident. The member is responsible for any amounts above the EasyShare amounts. In services where the member is responsible for the consultation fee EasyShare shares the balance up to program maximums.2.Emergency room cost sharing and ambulance limited to a maximum of 2 incidents per year.Emergency room/ambulance are only available for sharing if the intended for treatment of medical conditions that are life threatening or could seriously jeopardize the health of the individual and if the illness results in an in-patient hospital stay, inclusive of any other eligible, sharable medical expenses incurred throughout the Program Year.3.All outpatient CT Scan, MRI, and X-Ray imaging have a 90-day waiting period and sharable only with a physician prescription and must be procured at a free standing in-network diagnostic center unless received as an admitted patient. For CT Scan, MRI, and X-Ray imaging in a non-hospital environment EasyShare limits sharing to not more than$400 for CT Scan and MRI and not more than$250 for X- Ray with the member responsible for any amount above that limit. These diagnostic procedures are fully sharable if performed during an eligible, sharable inpatient stay and for an inpatient surgical procedure.viii.Sharing Amounts/Percentages.Sharing Percentages are not applicable to the EasyShare Programs. Sharing amounts/limits are shown above in section V, subsection vii, Per Medical Incident Limits.II. Medical Expense Sharing Medical costs are shared on a per person per Medical Incident basis for illnesses or injuries incurring medical expenses after your Effective Date that were medically necessary and provided by or under the direction of licensed Physicians, Hospitals or other licensed medical Facilities, or approved Practitioners.A Medical Incident means a medically diagnosed condition and all medical treatment(s) received andUHFR093021E100121 Page107 medical expenses incurred relating to such diagnosis. All medical bills of any nature relating to the same diagnosis are part of the same Medical Incident. Medical expenses eligible for sharing include, but are not limited to, physician and hospital services, emergency medical care, medical testing, x-rays, emergency medical transportation and prescription medications provided by a Hospital during an admission, unless otherwise limited or excluded by these Guidelines. Total bills incurred for medical costs must exceed the Annual Non-Sharable Amount established for your Program to be eligible for sharing (See Section 5.02 for details). Medical expenses must be submitted for sharing in the manner and form specified by Universal HealthShare. This includes the standard industry billing forms (HCFA 1500 and/or UB 92) and relevant/required medical records.The following Sections are designed to allow you to quickly check, based on type of health care facility, provider, service, product, treatment or physical/medical condition, to confirm whether a particular medical expense is generally sharable. Members share costs as addressed below, subject to both your prior payment of the applicable Annual Non-Sharable Medical Amount and all exclusions, restrictions and limitations set forth in these Guidelines. Any services not specifically referenced herein as either eligible or ineligible for sharing must be submitted to Universal HealthShare in advance for consideration and receive prior confirmation of general sharability to be eligible for sharing.i.Sharing for Facilities, Providers & Services Members generally share costs for the following health care facilities, providers, and services, as specifically described below. Note: All applicable Sharing Guidelines terms and limits of your sharing program, including the requirement for you to use an in-network provider and meet your Non-Sharable Amount apply.(a) Annual Routine Physical Exam.An Annual Routine Physical or Well Child Exam is sharable.(b) Ambulance.Emergency land or air ambulance transportation to the nearest medical facility capable of providing care that is medically necessary for a medical condition with symptoms of sufficient severity that the absence of immediate medical attention would reasonably be expected to result in death or serious jeopardy to the health of the individual (or, with respect to a pregnant woman, the woman’s unborn child) involving serious impairment to bodily functions or serious dysfunction of any bodily organ or part; provided, however, that air ambulance transportation is not sharable in situations where the use of a less expensive form of emergency transport could have been employed without materially increasing the risk of seriously jeopardizing your life or long-term health.(c) Audiological Procedures.N/A (d) Audiological Therapy.N/A (e) Chiropractic Therapy.N/A (f) Cologuard.After a 180-day waiting period, a Cologuard® noninvasive colon cancer screening test prescribed by a Physician may be sharable once every three (3) years for Members who are 45 or older, up to $650 perUHFR093021E100121 Page108 test for each Member, and the combined Preventive Care sharing limit will not apply to sharing for such tests.(g) Colonoscopy.A diagnostic colonoscopy is sharable when prescribed due to symptoms for a condition not evident prior to your membership. Routine or screening colonoscopies are not sharable.(h) Cosmetic Surgery.Cosmetic Surgery, including breast reduction or enhancement operations and any other elective cosmetic surgery or procedures done primarily to alter appearance or for any other non-health reasons, is not sharable.(i) CT Scan.For CT Scans in a non-hospital environment EasyShare limits sharing to a fixed amount of $400 per visit/series with the member responsible for any amount above that limit. All outpatient CT scan imaging have a 90-day waiting period, are sharable only with a physician prescription and must be procured at a free standing in-network diagnostic center unless received as an admitted patient.(j) Diagnostic Imaging See individual entries for CT scan, Mammogram, MRI, X-Ray imaging.(k) Emergency Room.Emergency room services provided on an outpatient basis at a Hospital, Clinic or Urgent Care Facility for stabilization or initiation of treatment of an Emergency medical condition, including when Hospital Admission occurs within 23 hours of emergency room treatment. EasyShare limits sharing to a fixed amount of $1,000 per visit and is only intended for Emergency treatment. Emergency room cost sharing is only intended for Emergency treatment, and Emergency Room expenses incurred for a non- Emergency situation will not be shared; provided, however, that for children six years and under any Emergency Room expenses will be presumed to be incurred for an Emergent Situation unless there is a compelling reason to conclude otherwise.(l) Hearing Surgery.N/A (m) Hearing Therapy.See Audiological Therapy.(n) Home Health Care.N/A (o) Hospice Care.N/A (p) Hospital Charges.Daily room and board charges up to a maximum of $2,500 per day for EasyShare 25 or $3,000 per day for EasyShare 50 for a maximum of 10 days annually for Inpatient hospital care or procedure for a medically diagnosed condition, but only when such care or procedure cannot be provided or performed on an outpatient basis or in a non-hospital, ambulatory facility. A separate sharable amount for an individual surgical procedure is available for up to $2,500 per procedure for EasyShare 25 or $3,000 perUHFR093021E100121 Page109 procedure for EasyShare 50 for up to two surgical procedures per program year. There is a 90-day waiting period before Hospital and surgical charges can be eligible for sharing.(q) Hyperbaric Oxygen Therapy.N/A (r) Infusion Therapy.N/A (s) Mammograms.Mammograms may be eligible for sharing once every two years for Members up to and including age forty-nine (49), and once every year for Members fifty (50) years of age and older, after the applicable waiting period. Only charges for conventional 2-D screening mammograms can be shared, not 3-D or other similar types of mammograms.(t) MRIs.For MRIs in a non-hospital environment EasyShare limits sharing to a fixed amount of $400 per visit/series with the member responsible for any amount above that limit. All outpatient MRI imaging have a 90-day waiting period, are sharable only with a physician prescription and must be procured at a free standing in-network diagnostic center unless received as an admitted patient.(u) Naturopathic and/or Alternative Treatments.N/A (v) Occupational Therapy.N/A (w) Organ Transplant.Expenses incurred in connection with any organ or tissue transplant are treated like any other hospitalization and surgical procedure and are subject to the same sharing limitations.(x) Physical Therapy.N/A (y) Physician Services.The EasyShare Program allows for immediate sharing for Primary Care, Specialty Care, Pediatric, and Urgent Care office visit physicians charges, as well as Preventive Services (the 90-day waiting period does not apply to these office visits). You must pay a Consultation Fee for each visit; this fee will be due at the time of your visit. After your payment of the Consultation Fee, the remaining portion of the physician charges for the office visit only will be eligible under this sharing category. Charges other than the actual Office Visit fee billed for physician services from that visit, such as testing, screening, imaging, and procedures, may be sharable if applicable, subject to requirements and limitations. (If multiple visits are required for an immunization that is eligible for sharing, the Member Consultation Fee will apply to the initial visit and the cost of the immunization and the subsequent office visit to complete the immunization will all be eligible for sharing.) If imaging is done both without and with a contrast agent, that is considered two separate imaging series and the Member Consultation Fee must be paid for both. Similarly, if imaging is done on two different body parts (e.g., head and leg), that is considered two separate imaging series and the Member Consultation Fee must be paid for both.UHFR093021E100121 Page110 (z) Plastic Surgery for Disfiguration.Medical care and treatment provided for disfiguration caused by amputation, mastectomy, disease or accident, including reconstructive mammoplasty or similar procedure performed by a general surgeon, is eligible for sharing. Any other plastic surgery or cosmetic care or treatment is ineligible for sharing, including but not limited to, pharmacological regimens; nutritional procedures or treatments; cosmetic surgery; salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal or revision of scars, tattoos or actinic changes.(aa) Prescription Drugs.The RxSimpleShare Prescription Drug Program is included in the Healthy Life EasyShare Programs.RxSimpleShare allows for the purchase of many common prescriptions for a $5 co-share. See section IX for details. Other prescription drugs are only eligible for sharing when provided by a Hospital as part of inpatient treatment or provided by a Facility during an outpatient surgical procedure.: (ab) PSA Test.PSA tests are eligible for sharing once every two years up to and including age forty-nine (49). PSA tests are eligible for sharing for members fifty (50) years of age and older once each year.(ac) Respiratory Therapy.N/A (ad) Speech Therapy/Speech Pathology.N/A (ae) Vision Therapy.N/A (af) Well Baby Visits.Well baby visits, including immunizations, are eligible for sharing within the first year of birth.(ag) Well Child Exam.See Annual Routine Physical Exam, above.(ah) X-Ray.For X-Rays in a non-hospital environment EasyShare limits sharing to a fixed amount of $250 per visit/series with the member responsible for any amount above that limit. All outpatient X-Ray imaging have a 90-day waiting period, are sharable only with a physician prescription and must be procured at a free standing in-network diagnostic center unless received as an admitted patient.ii.Sharing for Physical Conditions; Illnesses and Injuries.Expenses for most types of physical conditions resulting from Illness or Injury are generally sharable, subject to all applicable conditions and limitations set forth elsewhere in these Guidelines, although special provisions apply for certain conditions, as explained below: (a) Abortion in Specific Circumstances.Services, supplies, care or treatment in connection with an abortion may only be sharable if (a) the physical life of the mother is endangered by the continued Pregnancy and treatment via a cesarean section has been determined by a neonatologist to be inadvisable, or (b) the Pregnancy was the result of a rape or incest for which a police report was filed.UHFR093021E100121 Page 111 (b) Asthma.Asthma is generally sharable, but during the first 36 months membership, a Confirmation of No Prior Existence of Condition statement may be required.(c) Back Problems.Back problems are generally sharable, but during the first 36 months membership, a Confirmation of No Prior Existence of Condition statement may be required.(d) Bunions.Bunions are generally sharable, but during the first 36 months membership, a Confirmation of No Prior Existence of Condition statement may be required.(e) Cancer.Generally sharable, but limitations may apply if it is related to cancer of a type you had prior to becoming a Member (see Section 4.05(n)) and during the first 60 months membership, a Confirmation of No Prior Existence of Condition statement may be required.(f) Carpal Tunnel Syndrome.Carpal Tunnel Syndrome is generally sharable, but during the first 36 months membership, a Confirmation of No Prior Existence of Condition statement may be required.(g) Complications Arising from Maternity.Medical expenses for complications to the member are considered part of the maternity need.(h) Complications Arising from Sharable Medical Procedures.If complications arise from a medical procedure that is sharable, expenses for treating the complications are sharable unless the complication itself is not sharable under these Guidelines.(i) Dental Injury.Expenses for dental care are generally not sharable, with the following exceptions: i.Expenses for the treatment of natural teeth and caps (but not dentures or partial plates) that are broken/injured in an accident (but not an accident that occurs in the course of receiving dental care, when eating, or in certain motor vehicle accidents).ii.We do not share routine dental work such as (but not limited to): check-ups, cleanings (including deep cleanings), fillings, crowns, root canals, implants, removal of wisdom or infected teeth, dentures, bridges, anesthesia for routine dental care, or treatment of periodontal disease, except when these routine treatments are necessarily a part of surgery on the bones or other non-routine treatments. So, for example, if you have an infected tooth removed, that will normally not be sharable. But if the infection went into the jawbone and required removal of some of the bone, then the entire procedure would be sharable. Implants are not included because they always involve “surgery on the bone,” and there are usually less expensive alternatives.(j) Diabetes Diabetes is sharable, unless it is related to diabetes you had prior to becoming a member and it does not come within the exception described in Section VII.C.2. During the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.(k) Foot Disorders.Foot Disorders are generally sharable, but during the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.UHFR093021E100121 Page112 (l) Genetic Defects.Genetic Defects are sharable when at least one of the following is true: i.Neither the condition nor a symptom of the condition was discovered until after the then-current and continuously maintained membership had begun; ii.The condition has not required treatment or produced harmful symptoms, and has not deteriorated for at least five years; iii.The condition exists in a person who has been included in a membership from birth, and the member was included in a membership prior to the pregnancy; or iv.If the condition exists in a person who was adopted, the person has been included in a membership since the adoption, and the adopting parents were unaware of the condition at the time the adoption was finalized.(m) Heart Conditions.Heart Conditions are sharable unless related to a heart condition you had prior to becoming a member, and it does not come within the exceptions described in Section VII. During the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.(n) Hemorrhoids.Hemorrhoids are generally sharable, but during the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.(o) Hereditary Diseases.Hereditary Diseases are sharable under the same conditions as Genetic Defects.(p) Hernia.A Hernia is generally sharable, but during the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.(q) High Blood Pressure.As long as you have not been treated in a hospital for high blood pressure in the past four years, and you have been able to effectively and continuously control this condition through medication or diet, an incident that begins after your membership begins is sharable.(r) Pregnancy/Maternity.For a member who has been a Sharing Member continuously for at least twelve (12) months prior to conception, medical expenses for Maternity are eligible for sharing, subject to the applicable Annual Non- Sharable Medical Amount, as follows: i.Up to $5,000 per-pregnancy limit for a normal delivery or a cesarean section that is not medically necessary (whether for a single or multiple birth pregnancy), including but not limited to charges and expenses arising from physician care, hospital or birthing center admissions, attendance by midwives, or home deliveries accompanied by a midwife or physician.ii.Up to $8,000 per-pregnancy for Maternity ending in a delivery by cesarean section that is medically necessary because of complications that arise at the time of delivery (whether for a single or multiple birth pregnancy).iii.Up to $50,000 or the Program’s Annual Sharing Limit per pregnancy for Maternity ending in a natural delivery or cesarean section, for combined expenses for the member and newborn arising from complications at the time of delivery that threaten the life of the member or infant andUHFR093021E100121 Page113 requiring care or services not normally rendered at the time of delivery (whether for a single or multiple birth pregnancy).iv.In the case of an ectopic pregnancy diagnosed before a rupture, expenses eligible for sharing include costs of pre-operative tests, consultations and other expenses for keeping the member under medical care while determining what care should be offered for the Member and Child. In the case of an ectopic pregnancy that results in a ruptured fallopian tube, expenses eligible for sharing include surgery, post-operative recovery of the member, follow-up care, and treatment of any complications.In the case of an ectopic pregnancy, expenses eligible for sharing will be subject to the applicable per- Medical Incident limit, inclusive of costs of pre-operative tests, consultations and other expenses for keeping the member under medical care while determining what care should be offered and, in the case of an ectopic pregnancy that results in a ruptured fallopian tube, surgery, post-operative recovery of the member, follow-up care, and treatment of any complications.(s) Pre-Natal Care Visits.Visits for standard pre-natal care are generally sharable, subject to applicable visit limits.(t) Prostate Conditions.Prostate Conditions are generally sharable, but during the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.(u) Sexually Transmitted Diseases (STDs).HIV, AIDS, or other STDs contracted due to the actions of others (e.g., blood transfusions or medical procedures) will be shared. We do not share needs for sexually transmitted diseases, including the HIV virus and/or AIDS, when contracted through irresponsible behavior such as sharing hypodermic needles for legal or illegal drugs. It is the member’s responsibility to explain how the disease was contracted.(v) Sleep Apnea.Sleep Apnea is generally sharable, but during the first 36 months of membership, a Confirmation of No Prior Existence of Condition statement may be required.iii.Medical Expenses Sharable Under Limited Circumstances.1.Injuries Caused by Motor Vehicle Accidents.Most needs for motor vehicle related injuries are generally shared, but there are exceptions that are described below. For purposes of these Guidelines, any vehicle with a motor or engine that is used for transportation, work, or recreation is a “Motor Vehicle,” any person driving, riding or otherwise controlling a Motor Vehicle is the “Operator,” and any person other than the Operator riding in, on or being pulled by a Motor Vehicle is a “Passenger.” Before any medical expenses for Motor Vehicle related injuries will be considered for sharing, they must first be submitted to any party that is responsible for the accident or liable for damages resulting from the accident.2.Accidents where you are not an Operator or Passenger.Needs for injuries caused by or incurred in a Motor Vehicle accident where you were not an operator or passenger (e.g., you were a bystander, pedestrian, bicyclist, etc., when injured) are sharable, but only to the extent the costs at issue are not the responsibility of any insurance carrier or liable party.3.Accidents where you are an Operator or Passenger.Needs for injuries caused by or incurred in a Motor Vehicle accident in which you were an operator or passenger of an on-road or off-road Motor Vehicles (including cars, trucks, motorcycles, tractors, farmUHFR093021E100121 Page 114 implements, construction equipment, go-karts, four-wheel or six-wheel ATVs, golf carts, personal moving devices, and all types of motorized watercraft and aircraft) will be sharable, to the extent the costs at issue are not the responsibility of any insurance carrier or liable party, but only if: (a) the Operator(s)/rider(s) were driving, riding or operating the vehicle off-road or on a public roadway that permits Motor Vehicles of the type involved in the accident; (b) the Operator and Motor Vehicle were validly insured as required by law; (b) the Operator(s)/rider(s) and Motor Vehicle were not engaged in racing or stunt competition and were not operating the Motor Vehicle recklessly; and (c) the Operator(s)/rider(s) were not operating the Motor Vehicle under the influence of alcohol, any recreational drug, any prescription drugs that bear a warning against operating a Motor Vehicle or heavy machinery, or any illegal substance as defined by applicable law.4.Accidents involving three-wheel vehicles or snowmobiles where you are an Operator or Passenger.Expenses from injuries related to accidents involving three-wheel vehicles or snowmobiles in which you were an operator or passenger are not sharable, whether off-road or on-road, even if local law allows three-wheel vehicles or snowmobiles to travel on public roads.5.Occupational or Work-Related Injuries.Expenses arising from the care and treatment of an Illness or Injury that is occupational, or that arises from work for wage or profit, including self-employment, are generally not eligible for sharing. However, provided such Illness or Injury results from legal employment, they will be considered for sharing if: a) The State in which the injuries occurred has no Worker’s Compensation laws or insurance requirements; or b) The State laws proscribing participation in the Worker’s Compensation system of that State do not allow the business owner and/or enterprise from participating in Workers Compensation. Documentation of such exemption may be required.iv.Conditional Member Expenses.Members with certain pre-existing conditions that are responsive to lifestyle changes may be accepted into the membership based on a mutually agreed upon treatment plan between the Conditional Member and Universal HealthShare. Conditional Members are assigned a health coach to monitor and encourage personal progress toward health goals. Health coaching sessions and related costs, including administrative fees charged by Universal HealthShare in its reasonable discretion, shall be paid for by the Conditional Member by remitting a monthly amount set, and revised from time to time, by Universal HealthShare. Certain expenses associated with that customized treatment plan may be eligible for sharing based upon review and case by case determination by Universal HealthShare, to include, but not be limited to, smoking cessation, weight loss or dietary control, diabetic testing supplies, or other program costs that may be eligible for sharing as an incentive to lifestyle change. The normal pre-existing condition guidelines may be altered at the discretion of Universal HealthShare to encourage participation in the Conditional Membership program as conducted, revised and implemented by Universal HealthShare.UHFR093021E100121 Page 115 III. Out-of-Network Physician Charges are Not Sharable If medical charges are incurred from providers and/or facilities that are out of network, the following guidelines will be used to determine sharable amounts for those charges. (You can always determine in advance whether a provider is out of network by asking your physician or hospital, or by contacting your Customer Service team.) Out-of-network physician services are not eligible for sharing except for emergency room visits, charges that are part of sharable inpatient hospitalization and surgery, or sharable outpatient surgical procedures.If eligible, these charges will be sharable at a percentage of the Medicare payable amount. Ask your provider or call your Customer Service team for details.IV. Sharing for Pre-Existing Conditions All rules related to Pre-Existing Conditions referenced in the Guidelines apply to the UHS Healthy Life EasyShare Programs, subject to the following exception: Conditions that exist at the time of enrollment that have evidenced symptoms and/or received treatment and/or medication within the 36 months prior to enrollment are not eligible for sharing during the first to years of Membership, except where specifically noted within these Sharing Guidelines. After the first two full years of continuous monthly membership, medical expenses incurred for a pre-existing condition are eligible for sharing up to the annual program limits inclusive of any other eligible, sharable medical expenses incurred throughout the Program Year, as if the condition was not pre-existing. For certain conditions listed in Article VI, Section 6.02, a statement signed by both the member and the doctor must be submitted, verifying that the condition did not exist prior to membership, or that the member went at least 36 and in some cases 48 months (up to 60 months for some conditions, such as cancer) without symptoms, treatment and medication subsequent to the time the condition last occurred or existed occurred prior to the individual becoming a member (“Confirmation of No Prior Existence”).