Solidarity Healthshare Sharing Guidelines Update: November 1, 2021

Effective November 1, 2021, we updated our Sharing Guidelines and want to note some of the larger changes that you can expect.

 

Changed Program Language:

A. Solidarity ONE. (IV. A.)

Solidarity ONE is our most comprehensive program and allows the Member to select the level of sharing participation to determine the Monthly Contribution Amount, the Annual Unshared Amount and Senior Discount.  Members mutually Share Eligible Medical Expenses up to $1 million per Incident per year.

B. Solidarity Legacy Premier. (IV. B.)

Solidarity Legacy Premier allows Members to mutually Share Eligible Medical Expenses up to $1 million per Incident per year and is not available for new Members.

 Added:  Changes in Membership Participation  (V. D.)

Changes in participation of the Membership, including but not limited to, changes to primary Member of the Membership; Monthly Contribution; and Annual Unshared Amount may result in resetting the Program Year and the Annual Unshared Amount for the Membership. During the Program Year, the Membership cannot be changed to lower the Annual Unshared Amount.

Added Language in bold - (VI. A)

To maintain active Membership, Sharing Members must submit Membership Dues and a Monthly Contribution of at least the minimum amount suggested by Solidarity HealthShare. Only Sharing Members with an active Membership will have their Eligible Medical Expenses Shared.  The suggested Monthly Contribution consists of the Monthly Share Amount, administrative fee, program service fee, and account service fee.    Any amount contributed over the suggested Monthly Contribution will be a donation to Solidarity HealthShare Foundation, Inc.

Changed Language in bold - (VI. A. (3))

Administrative Fee. Solidarity HealthShare administrative fee includes the expenses for administrative, management or general expenses.  The amount of the administrative fee may be revised at any time by majority vote of the Board of Directors. Notice of a change will be given to the Members in a timely manner.

Added Account Service Fee - (VI. A. (5))

Account Service Fee

Solidarity HealthShare account service fee is for the costs of processing the Monthly Contribution and can be discounted if the Member uses Automated Clearing House (ACH) for the Monthly Contribution.

Added Language in bold - (VI. C.)

As a help to other Sharing Members, any Member who desires to withdraw their participation should send written notice of their cancellation, including the reason for such cancellation, by the first (1st) day of the month prior to the month in which the Member intends to withdraw membership. If a Member withdraws more than thirty (30) days after their Membership effective date, Membership fees will not be refunded.

If a Sharing Member has withdrawn their participation and wishes to become active again, he/she must reapply as a new applicant and will not receive preferential treatment as his/her application is considered for acceptance. Reactivating membership gives Sharing Members a new effective date and does not retroactively move the previous effective date forward.

Changed Inactive Membership to reflect non-sharing of Eligible Medical Expenses if membership is inactive (VI. D.)

 If a Sharing Member does not voluntarily contribute the suggested Monthly Contribution for two (2) consecutive months, the Sharing Member’s status will be changed to “Inactive Member” with the effective date of inactivation of the first missed Monthly Contribution.

The Sharing Member will not be expected to submit the missed suggested Monthly Contributions; however, Eligible Medical Expenses while an Inactive Member will not be eligible for Sharing.  If the Sharing Member contributes the suggested Monthly Contribution for each past due month, Eligible Medical Expenses, will be eligible for Sharing.

If a Sharing Member has been changed to Inactive Member and wishes to become active again, he/she must reapply as a new applicant and will not receive preferential treatment as his/her application is considered for acceptance. Reactivating membership gives Sharing Members a new effective date and does not retroactively move the previous effective date forward.”

Changed to add drug and alcohol counseling and removed limits of 20 visits - (VII. A. (15))

Mental Health Services. Expenses for counseling, drug and alcohol counseling, treatment, medication, and emergency hospitalizations are eligible for Sharing.

Added VII. A. (22):  Prescription Drugs and Supplements.

(a) Solidarity ONE Members.  Prescription drugs are eligible for Sharing.  Members have access to Drexi Pharmacy Sharing for retail prescription drugs based on the current formulary and co-share schedule.  Supplements, including, but not limited to, phytotherapeutics, vitamins, and herbs are eligible for Sharing ninety (90) days after the onset of each related Incident.

(b) Solidarity Legacy Premier Members. Members have access to Drexi Pharmacy Wholesale program which provides access to discounts on certain prescription drugs.  Prescription drugs and supplements, including, but not limited to, phytotherapeutics, vitamins, herbs, and approved drugs are eligible for Sharing ninety (90) days after the onset of each related Incident.  Prescription Drugs obtained from Drexi participating pharmacies are eligible for Sharing, however, Legacy Premier Members must pay for the prescription drugs and submit to Solidarity HealthShare for Sharing. 

Changed Wellness Visits - Reworded Wellness Visits to clarify what is included in Wellness Visits and to follow the Solidarity Wellness policy. (VII. A. (27))

Wellness Visits.  Charges for one (1) wellness exam or physical per Program Year are eligible for Sharing, before applying the Annual Unshared Amount, and include but not limited to screening labs (CBC, CMP, lipids, hemoglobin A1c, vitamin D, and CRP).  Sharing Members in the first two (2) years of life have seven (7) well-child visits for the first year and three (3) well-child visits for the second year eligible for Sharing.  Other screening services including pap smears/HPV testing, screening colonoscopies, Prostate-Specific Antigen (PSA), DEXA scans, and breast imaging (screening mammogram/thermography) may be eligible for sharing following the Solidarity wellness policy.

Changed treatment to procedures so prescriptions drugs can be eligible for sharing for drug and alcohol counseling. (VII. B. (2))

Alcohol/Drug Addiction. Services, supplies, care, or procedures for an injury and/or disease and/or bodily malfunction resulting from a Sharing Member’s abuse and/or use of alcohol or drugs/pharmaceuticals, including drug and/or alcohol Rehabilitation Treatment.

Deleted last line -  Outpatient Prescribed/Non-Prescribed Medical Supplies/Personal Comfort Items. (VII. B. (26))

Outpatient prescribed/non-prescribed medical supplies or equipment and personal comfort items are not eligible for Sharing, including, but not limited to, ace bandages, air conditioners, air-purification units, blood pressure instruments, diabetic test strips, elastic bandages, elastic stockings, electric heating units, first-aid supplies, gauze, humidifiers, insulin infusion non-hospital adjustable beds, orthopedic mattresses, ostomy supplies, over-the-counter drugs and treatments, pumps, scales, syringes, tubing, and masks. Please see Solidarity Care CardSM for discounts.

Added: VII C. (2) Timely Submission of Needs

Needs do not qualify for Sharing unless the Sharing Member submits a request for Sharing and documentation of Eligible Medical Expenses within ninety (90) days of receipt of the Healthcare Service or the date of discharge, as applicable.   Failure to submit the request for Sharing within 90 days will not invalidate or reduce Shareable amount if submission within 90 days was not reasonably possible, so long as the request for Sharing is submitted within one (1) year.

Added language in bold -  Annual Unshared Amount. (VII C. (3))

Eligible Medical Expenses are not eligible for Sharing until the Eligible Medical Expenses exceed an Annual Unshared Amount for each Single, Couple, or Family Membership.  The Annual Unshared Amount shall be calculated upon the Program Year for each Member.  The Annual Unshared Amount is applied to the Program Year based upon the date the Shareable Healthcare Service occurred.  Any changes to the Membership may reset the Annual Unshared Amount.  See V. D.

Changed Language in bold: Excess Charge or Excessive Charges. (VII. C. (8))

 Members must take steps to ensure that charges for Shareable Healthcare Services are reasonable.  Excess Charges do not qualify as Eligible Medical Expenses and are not eligible for Sharing.  As part of its administrative services, Solidarity HealthShare will assist Members in communications with Providers to avoid Excessive Charges.  In furtherance of the shared beliefs of all Members, it is the mission of Solidarity HealthShare to assist Members in managing, controlling, and directing their individual healthcare and the costs of that care. This includes the duty of Solidarity HealthShare to protect its Members from unfair and unreasonable charges submitted by Providers of healthcare services. Solidarity HealthShare reserves the right, on behalf of its Members, to determine what part of an expense for the care and treatment of an injury or illness is unfair or unreasonable, based on techniques, criteria, and standards established or adopted by Solidarity HealthShare. It is the intention of Solidarity HealthShare to limit the Sharing of charges determined to be excessive, unfair or unreasonable and we will advocate on behalf of Sharing Members against any Provider demanding payment of such unfair charges.   If the Provider seeks to collect the Excessive Charges, Solidarity HealthShare will, with the cooperation of the Member, undertake reasonable efforts to minimize the Member’s liability for the Excess or Excessive Charges.  Solidarity HealthShare makes no representations or warranties as to the success of such efforts. 

Changed language in bold:  Direct Primary Care (DPC). (VII. C. (10))

Direct Primary Care monthly fees are eligible for Sharing up to $375 for a single membership, $750 for a couple membership, and $1250 for a family membership.

Added:  X. B. (2)

Participate in and support efforts by Solidarity HealthShare to negotiate with Providers to reduce or avoid Excess Charges;

Added:  XI. A. (3)

Health Sharing Delegate means a person or entity to which Solidarity has delegated certain functions related to Member requests for Sharing, including but not limited to determining Reasonable Charges and assisting Members with Excess Charges.

Added:  XI. A. (4)

CMS means the Centers for Medicare & Medicaid Services, the agency within the U.S. Department of Health and Human Services that is responsible for administering the Medicare program.

Added:  XI. A. (5)

CMS Cost Ratio means the ratio of facility costs to charged amounts as utilized by CMS in determining facility (inpatient or outpatient) reimbursement or as reflected in a Hospital’s most recent available departmental cost ratio report to CMS and published as the “Medicare Cost Report” in the American Hospital Directory.

 Added:  XI. A. (6)

Cost(s) means: (a) as to Healthcare Services provided by a Hospital or Physician, the costs determined from review and analysis of a facility’s applicable CMS Cost Ratios; (b) as to medical and surgical supplies, implants and devices, the costs to the Hospital or Physician of such items, which may be established by a Hospital or Physician invoice or a certified statement from a representative of the Hospital or Physician or, in the absence of a such an invoice or statement, through other sources of cost information or comparative data, such as comparable invoices, receipts, cost lists or other documentation or resources published or publicly available (free, for purchase or by subscription), or any combination thereof, that are deemed sufficient, in the opinion of Solidarity or its delegate; (c) as to pharmaceuticals provided by a Hospital, acquisition cost determined by reference to the National Average Drug Acquisition Cost calculated by CMS, the Average Acquisition Cost (AAC) for the state in which the facility resides, the Predictive Acquisition Cost calculated by Glass Box Analytics, or other comparable and recognized data source; and (d) as to medical and surgical supplies, implants and devices provided by a Hospital, acquisition cost determined by reference to an invoice submitted by a Hospital or, in the absence of such an invoice, a written statement from the Hospital specifying its actual acquisition cost or, in the absence of such an invoice or written statement, through other documentation or sources of cost data such as, but not be limited to, comparable invoices, receipts, cost lists or other commonly recognized data source, or other documentation or sources of cost information deemed appropriate by Solidarity or its delegate.

Added:  XI. A (9)

Drexi Pharmacy Sharing means a program offered by Advanced Medical Pricing Solution Services (AMPS) and is available to Solidarity One Members.  Drexi Pharmacy Sharing provides Member access to certain retail prescription drugs on a co-sharing amount, meaning Member may have to pay part of the cost of the prescription drugs and the remainder will be submitted for Sharing among the Members.  Drexi Pharmacy Sharing is not an insurance program and Solidarity HealthShare in not affiliated with AMPS.  Certain prescription drugs may be subject to prior approval of Solidarity HealthShare or its designee in order to be Eligible for Sharing.  A request for prior approval will be handled by and the decision of Solidarity HealthShare will be communicated to the Drexi participating pharmacy when Solidarity ONE Member submits a prescription.

Added:  XI. A. (10)

Drexi Pharmacy Wholesale means a program offered by Advanced Medical Pricing Solution Services (AMPS) and is available to Solidarity Legacy Premier Members.  Drexi Pharmacy Wholesale provides Member access to discounts on certain prescription drugs; it does not pay for the cost of any prescription drugs and the Member must pay for the prescription drugs and submit the Eligible Medical Expenses to Solidarity HealthShare for Sharing.  Drexi Pharmacy Wholesale is not an insurance program and Solidarity HealthShare is not affiliated with AMPS.

Added:  XI A. (13)

Excess Charge(s) or Excessive Charge(s) means charge(s) for Healthcare Services that are greater than the Reasonable Charges as determined by Solidarity HealthShare, or its Health Sharing Delegate.

Added:  XI. A. (17)

High Dollar Drugs means pharmaceuticals generally categorized as “orphan drugs” or “specialty drugs” or other high-cost drugs, including, without limitations, biologicals, oncology drugs, bone morphogenetic proteins, nucleotide analog combinations, antiretroviral therapies, intravenous immunoglobulin, and any drug that costs more than $10,000 for a course of treatment or during the course of any single episode of care.

Changed:  XI. A. (26)

Monthly Contribution means the amount the Member contributes on a monthly basis and consists of the Monthly Share Amount, administrative fee, program service fee and account service fee.

Added:  XI. A. (28)

 OPPS Reimbursement means the amount that would be paid for the Healthcare Service in accordance with the Hospital Outpatient Prospective Payment System (“OPPS”) used by CMS.

Added:  XI. A. (35)

Permitted Payment Level means, in the discretion of Solidarity HealthShare, charges for Healthcare Services which are necessary for the care and treatment of Illness or Injury not caused by the treating Provider. The Permitted Payment Level will be determined by Solidarity HealthShare or the Health Sharing Delegate, under a reference based pricing analysis and taking into consideration: unusual circumstances or complications requiring additional time, skill and experience in connection with a particular Healthcare Service; industry standards and practices as they relate to similar scenarios; and the cause of injury or illness necessitating the Healthcare Services. Solidarity HealthShare retains discretionary authority to determine whether Healthcare Services or charges for Healthcare Services are reasonable based upon information presented to Solidarity HealthShare.

(a) For Hospitals:

(i)  Inpatient Services.  The Permitted Payment Level is based on the average of 150% of the Medicare Allowable Amount and 135% of the Cost of the Medical Care; provided, however, that to the Permitted Payment Level may not exceed 175% of the Medicare Allowable Amount or the amount of Usual, Customary and Reasonable Fees.

(ii)  Outpatient Services.  The Permitted Payment Level is based on the average of 150% of the Medicare Allowable Amount for the Healthcare Services and 135% of the Cost of the Medical Care; provided, however, that the Permitted Payment Level shall not exceed 175% of the Medicare Allowable Amount or the amount of Usual, Customary and Reasonable Fees.

(b) Ambulatory Surgery Centers & Independent Facilities. The Permitted Payment Level is based on the average of 150% of the Medicare Allowable Amount and 135% of the Cost of the Medical Care; provided, however, that the Permitted Payment Level shall not exceed 175% of the Medicare Allowable Amount or the amount of Usual, Customary and Reasonable Fees.

(c)  Other Medical & Surgical Services. The Permitted Payment Level for any general medical and/or surgical Healthcare Services is based on the average of: 

(i) allowable reimbursement amounts for such Healthcare Services according to the OPPS Reimbursement or other Medicare fee payment methodology plus an additional 20%;

(ii) the Costs for such Medical Care plus an additional 12%; or

(iii) the Usual, Customary and Reasonable Fees as reflected in, or determined by reference to or through the use of any other industry-standard resources or widely recognized data sources, including any resources listed above or any other fee and/or cost information, sources, lists or comparative data published or publicly available (free, for purchase or by subscription), or any combination of such resources that are sufficient, in the opinion of the Health Sharing Delegate, to determine a Reasonable amount of Medical Care Shared by the Plan.

(d)  Pharmaceuticals.  The Permitted Payment Level for pharmaceuticals received from any Hospital or independent facility is based on:

(i) 150% of Cost for pharmaceuticals other than High Dollar Drugs, but not to exceed the Usual, Customary and Reasonable Fees for such pharmaceuticals; or

(ii) 120% of Cost for High Dollar Drugs; but not to exceed the Usual, Customary and Reasonable Fees for such pharmaceuticals.

(e)  Supplies, Implants & Devices.  The Permitted Payment Level for medical and surgical supplies, implants and devices is based on 120% of the Cost to the Hospital or independent facility providing such items.

(f)   Dialysis Services and Infusion Therapy.  The Permitted Payment Level for dialysis services and infusion therapy visits (which shall include dialysis, facility services, supplies and medications provided during treatment) is based on the Medicare Allowable Amount for the billing Hospital or Physician in light of clinical considerations pertinent to the patient being treated.

(g)  Medical Care Provided Under Direct or Indirect Agreement. The Permitted Payment Level for Medical Care provided by Hospitals or Physicians that holds a direct or indirect agreement with Solidarity will be the rates or fees established under such agreement.

Solidarity HealthShare may, in its sole discretion, taking into consideration specific circumstances, deem a greater amount to be the Permitted Payment Level. Solidarity HealthShare may take any or all of such factors into account but has no obligation to consider any particular factor. Solidarity HealthShare may also account for unusual circumstances or complications requiring additional or a lesser amount of time, skill, and experience in connection with a particular service or supply, industry standards and practices as they relate to similar scenarios, and the cause of injury or illness necessitating Healthcare Service and charges.

Changed:  XI. A. (38)

Reasonable Charges means, the Permitted Payment Level for Sharable Healthcare Expenses as determined by Solidarity HealthShare or the Health Sharing Delegate.

Added:  XI. A. (39)

Senior Discount means a discount applied to the Monthly Contribution in Solidarity ONE and Solidarity Legacy Premier that is available to Members who are enrolled in Medicare Parts A & B.

Change:  XI. A. (44)

Solidarity Care CardSM means the discount program, offered by Careington International Corporation, that is available to Solidarity One and Solidarity Legacy Premier Members.  The Solidarity Care CardSM provides access to Telehealth and discounts on Eye care and Dental Care.  The Solidarity Care CardSM is not an insurance program.  Solidarity HealthShare is not affiliated with Careington International Corporation. Information on the Solidarity Care CardSM is available at www.solidaritycarecard.com.

Added:  XI. A. (46)

Usual, Customary and Reasonable Fees means the fees identified by Solidarity HealthShare, or the Health Sharing Delegate, to be usual, customary and reasonable for the Healthcare Service, taking into consideration the fee(s) which the healthcare provider most frequently charges and/or accepts as payment for the service or supply from the majority of its patients, the cost to the healthcare provider for providing the Healthcare Service, the prevailing range of fees charged and/or accepted for the service or supply by healthcare providers of similar training and experience in the same geographic locale or area, and the Medicare reimbursement rates for the service or supply. The term(s) “same geographic locale” and/or “area” mean a metropolitan area, county, or such greater area as is necessary to obtain a representative cross-section of persons or organizations rendering such Healthcare Services for which a specific charge is made or for which a reimbursement is accepted. To be a Usual, Customary and Reasonable Fee, fee(s) must be in compliance with generally accepted billing practices for unbundling or multiple procedures.

 

You can view the full updated Sharing Guidelines here.

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