Pre-Membership Conditions

Pre-membership medical conditions are health conditions that existed prior to a member joining Zion HealthShare, and they are subject to specific sharing limitations to keep costs manageable for all members. Here’s how pre-membership conditions work in Zion HealthShare:

Definition of a Pre-membership Condition
A pre-membership medical condition is defined as anything for which a member has:

• Been examined,

• Been diagnosed,

• Taken medication,

• Had symptoms,

• A personal history of or known increased risk of conditions that may arise or worsen in pregnancy, or

• Received medical treatment within the 24 months prior to their membership start date.

Sharing requests related to pre-membership conditions are only eligible for sharing without the phase-in period if the condition was regarded as cured, did not require treatment, or present symptoms for 24 months prior to the membership start date.

Phase-In Period for Sharing Pre-membership Conditions

Zion HealthShare implements a phase-in period to manage the sharing of pre-membership conditions. This is a graduated system that allows for limited sharing of medical expenses related to pre-existing conditions over time:

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1. Year One: During the first year of membership, no sharing is allowed for pre-membership conditions.

2. Year Two: Starting from the second year, up to $25,000 is shareable for each sharing request related to a pre-existing condition.

3. Year Three: In the third year of membership, the shareable amount increases to $50,000 per sharing request.

4. Year Four and Beyond: After the fourth year, members can share up to $125,000 per sharing request for pre-existing conditions.

Each 12-month period resets the shareable maximum, meaning that if the condition continues beyond the current year, a new phase-in limit will apply.

Exceptions for Certain Conditions
Some conditions—specifically high blood pressure, high cholesterol, and diabetes (types 1 and 2)—are not considered pre-membership medical conditions if:

1. The member has not been hospitalized for the condition in the 12 months prior to joining, and

2. The condition is controlled through medication or diet.

Restrictions and Eligibility

• Pre-membership conditions that are under control (without treatment or symptoms for 24 months prior to membership) are not considered pre-existing and may be shareable.

• Certain conditions, such as arthritis or degenerative conditions, are automatically classified as pre-membership conditions and are subject to the phase-in period for sharing.

Additional Giving Fund. 

For pre-membership conditions that exceed the phase-in limits, members may apply for assistance from the Additional Giving Fund. This fund, supported by voluntary contributions, can provide extra help for members facing significant expenses related to pre-existing conditions.

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In summary, Zion HealthShare allows for the gradual sharing of pre-membership conditions over time, providing financial support while also managing the financial risk to the community.