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OneShare Health’s

Glossary of Terms

As your chosen Health Care Sharing Ministry (HCSM), OneShare Health strives to provide access to the best possible care for you and your family. In order to help you better navigate your Membership and some of the associated health share terminology, we’ve put together a ‘Glossary of Health Share Terms.’

 

For your convenience, we've outlined terms that OneShare, as an HCSM, acknowledge and which you may continue to reference throughout your OneShare Health Membership1. OneShare Health is not insurance, we are a Health Care Sharing Ministry (HCSM) that facilitates the sharing of medical bills among its Membership. You can also find all of our terms, definitions, disclaimers, and a full list of your Eligible and Ineligible Services in your Member Guidebook.

 

To view an online copy, go to your OneSource Member Portal or visithttps://www.onesharehealth.com/member-guidebook.

ACA-Exempt

As with all HCSMs under 26 USC § 5000A(d)(2)(B)(ii) of the Affordable Care Act, OneShare’s Members are exempt from the ACA and are not subject to the individual mandate. Additionally, OneShare is not subject to requirements under the Act, such as, but not limited to, the sharing of expenses related to Pre-Existing Conditions. OneShare does not assume any legal risk or obligation for payment of Member medical expenses. Neither OneShare nor its Members guarantee or promise that medical bills will be paid or shared by the Membership.

Accident

An act or event which is unforeseen, unexpected, and unanticipated, and which is the direct cause of any injury Eligible for Sharing, occurring after the Member’s Active Date.

Active Date

The date on which a Member's OneShare Membership becomes active and certain medical expenses become Eligible for Sharing according to the Guidelines.

Acute Illness

Any illness characterized by signs and symptoms of rapid onset and short duration. Signs and symptoms may be routine or severe and temporarily impede normal functioning.

Ambulance

A medically equipped land or air vehicle which transports patients to hospitals. Ambulances are used to respond to medical emergencies by emergency medical services.

Balance Bill

Fair and Reasonable Sharing is OneShare Health’s model that facilitates sharing at a fair amount when compared to services performed. We start with approving an amount based upon a percentage above the Provider’s Medicare rate. If a Provider does not accept that amount, we will advocate on your behalf with the Provider to significantly reduce their charges, when appropriate.

In cases where the Provider (typically the Provider Billing Department) overcharges for services, you may receive a balance bill. We will contact the Provider Billing Department to discuss the charge(s) and attempt to negotiate a fair and reasonable price for the services performed.

Contribution Amount

The monetary contribution voluntarily given by a Member to OneShare. It is a fixed dollar amount, a portion of which will be dedicated to share in other Members’ Eligible medical expenses as assigned by OneShare according to the Membership Guidelines. This amount must be submitted by the Member before any of the Member’s medical expenses during the applicable period will be considered for Sharing.

Date of Service

The date on which a health care service was provided.

Dependent

An individual must be either the Primary Member’s spouse or unmarried child; including a natural child (from the moment of birth if born after the Program Effective Date), a stepchild, adopted child, Eligible foster child, or grandchild (residing with Primary Member). The Dependent child must be defined as a legal Dependent of the Primary Member for maintenance and support, and must be under the age of twenty-seven (27)2 at the beginning of the Program Year. Disabled Dependent children over age 27 and who are financially dependent upon the Primary Member are Eligible to continue on the Program as a Dependent. Proof of disability and dependency is required within 31 days following such 27th birthday.

Eligible for Sharing

The charge for a medical service which is approved for sharing and which does not exceed any applicable limits

Emergency Room (ER)

Emergency Care provided on an Outpatient basis at a Facility.

Emergency Care

Medical care provided for the stabilization or treatment of a Life-Threatening or Life-Altering condition.

Equivalent/Alternative Care

Non-experimental health care treatment which may deliver care that is more cost effective, less invasive, and within generally accepted medical practice, may be Eligible for Sharing. Pre-Notification is required from OneShare Health; see definition of ‘Pre-Notification.

Explanation of Sharing (EOS)

A statement sent to the Member and Provider(s) with an explanation of OneShare Health’s assignment to Member sharing of Medical Expenses submitted.

Facility

Refers to any Facility that provides medical services on an Outpatient basis, whether a Hospital-affiliated or independent Facility.

Fair and Reasonable Amount

The amount approved for sharing for certain Eligible Expenses. The Fair and Reasonable Amount is calculated using several methods, including a percentage of an objective benchmark for the services provided.

Freedom of Choice; Freedom to Choose a Provider

Traditionally, consumers are in the habit of seeking medical services through a defined Provider Network – if a doctor or hospital isn't on the list, benefits are reduced. That's not the case with the new OneShare Health Programs. So go where you'd like, your Program Features will not be affected.

As a OneShare Health Member, we are giving you the freedom to choose a healthcare Provider; to go to any hospital or Facility you’d like. That way, we can help lower Out-of-Pocket expenses for your care and stretch your healthcare dollars.

To bring you this no-restriction freedom of choice, we facilitate sharing at a Fair and Reasonable Amount for Eligible Inpatient, Outpatient, Hospital, Surgery Center, or Clinical Lab Facility care!

Guidelines

The terms Guidelines, Sharing Guidelines, and Membership Guidelines all refer to the Membership Guidelines.

Health Care Sharing Ministry (HCSM)

A nonprofit religious organization that facilitates the sharing of medical expenses among its members in accordance with as an expression of their commonly held religious beliefs.

Home Health Care

Services for intermittent skilled nursing care and rehabilitative therapy that can be given in a Member's home for an illness or injury. Services provided by an individual who ordinarily resides in the Member’s home or is a member of the immediate family of the Member are Not Eligible for Sharing.

Hospital

An institution that is licensed to provide medical and surgical treatment for sick and injured individuals and is accredited by the Joint Commission on Accreditation of Hospitals sponsored by the AMA and the AHA.

Incident

An injury or illness of the Member that requires medical attention from a licensed Provider.

Not Eligible (or Ineligible) for Sharing

A type of Medical Expense which is either listed as Not Eligible for Sharing or not listed as Eligible for Sharing in the Guidelines.

Inpatient Hospitalization

Medical services received at a Facility for a period of 24 hours or more or for which there is an overnight admission.

Individual Sharing Amount (ISA)

The amount that a Member is responsible for paying to the Provider of medical services before the Member’s Medical Expenses are Eligible for Sharing under the Program. ISA applies to Program Year.

Laboratory Services

A medical laboratory or clinical laboratory is a laboratory where tests are usually done on clinical specimens in order to obtain information about the health of a Member as pertaining to the diagnosis, treatment, and prevention of disease.

Life-Threatening or Life-Altering

A condition which, if not immediately in receipt of medical treatment, has a high likelihood of causing death, or causing major irreversible bodily harm (including, for example: loss of arm, leg, hand or foot; loss of sight or hearing; paralysis, or loss of brain function.) The following are key signs and symptoms of Life-Threatening emergencies: respiratory distress or cessation of breathing; severe chest pains; shock; uncontrolled bleeding; choking; poisoning; prolonged unconsciousness; severe burns; any complaint or observation which indicates head or spinal cord injury. The following are examples of Life-Altering emergencies: broken bones; visible bones; or dismemberment.

Lifetime Program Maximum

The maximum amount of sharing per Member for the life of the Program. Once the Member’s limit is met, the Member is no longer Eligible to submit medical expenses for sharing under the Program.

Maternity

The Medical Expenses for the mother’s prenatal, delivery, and hospital, birthing center, or midwife services (related to home-birthing expenses). Maternity does not include Complications of Pregnancy or medical needs for the Newborn, which are subject to other provisions in the Guidelines.

Maximum Limit Per Incident

The maximum amount which may be shared for all Eligible Expenses related to a single incident under the terms of the Membership Guidelines

Medical Expense(s)

The charge(s) or expense(s) for medical services from a Provider for a Member.

Medically Necessary, or Medical Necessity

Those health services provided by a Provider for the purpose of preventing, diagnosing, or treating an injury or illness according to the accepted standards of medical practice.

The service must be:

  1. For the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms.
  2. In accordance with the generally accepted standards of medical practice.
  3. Clinically appropriate in terms of type, frequency, extent, site, duration, and considered effective for the patient’s illness, injury, or disease.
  4. Not primarily for the convenience of the patient, health care Provider, or other Physicians or health care Providers.
  5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness or injury.
Member

A Primary Member or Dependent enrolled in the Program.

Membership Program Year

Membership Program Year is defined as 12 months from the Active Date. Each additional Program Year will begin on the anniversary of the Active Date. Program Year applies to all facets of a Member’s program except the application of the Maximum Limit Per Incident and Lifetime Maximum Sharing.

Mental Health Support3

Bella, the Intuitive Mental Health Chatbot, connects 24/7 via the Clever HealthTM App to support you in the moments you need it most. The AI-powered mental health coaching chat specializes in anxiety and depression, provides self-help content and coping techniques, is 100% anonymous, and is accessible 24/7/365!

To access the Intuitive Mental Health Chatbot from Clever HealthTM, download the Clever HealthTM App!

OneShareBox

OneShareBox is a digital dashboard that allows transparency into where your Monthly Contribution Amounts go, whether it’s to Members in need or to our partner charities. Members can easily use OneShareBox to view their shared Contributions and personal sharing information in real time.

Outpatient

Medical services received at a Facility for a period of less than 24 hours and for which there is not an overnight admission.

Physician Office Visit

Licensed Medical Professional/Physician Office visits for the diagnosis, non-surgical treatment, or management of an illness or injury.

Physician

A person who is licensed to perform certain medical services issued by a state medical board. A Physician cannot be the Member or relative of the Member by blood or marriage and cannot reside in the household of the Member.

Practitioner

Refers to a person legally entitled to perform certain medical services who holds one of the required licenses or degrees, and who is acting within the scope of his or her licensure when performing such services. A Practitioner cannot be the Member or a relative of the Member by blood or marriage and cannot reside in the household of the Member.

Pre-Existing Condition 24/24

Pre-Existing Condition means: (1) any sickness or injury for which a Member, within 24 months before the Member’s Active Date, received medical treatment, advice, care, or services (including diagnostic measures), took prescribed drugs, or showed signs and symptoms (whether treated or not), or (2) any chronic, persistent, or long-lasting medical condition which is unresolved and known to the Member, regardless of whether, within 24 months before the Member’s Active Date, the condition required treatment, advice, care, services, or prescription drugs, or exhibited any signs or symptoms. Eligibility for a Pre-Existing Condition, or for any medical condition caused by or directly related to a Pre-Existing Condition, has a 24-Month Waiting Period.

Pre-Notification

A process the Member or the Member’s health care Provider follows to notify OneShare Health prior to receiving the specified medical services.

Prescription

Any written authorization by a medical Practitioner that authorizes a Member to be provided a medicine or treatment.

Preventive Services / Wellness Visit

Routine health care that includes checkups, patient counseling, and screening to prevent Illness, disease, and other health-related problems. A Wellness Visit is prevention-focused and not medically necessary to treat Illness or Injury.

Primary Care Physician (PCP)

A Physician in family practice, internal medicine, obstetrics/ gynecology, or pediatrics who is a patient’s first contact for health care in an ambulatory setting. A Primary Care Physician cannot be a Member or relative of the Member by blood or marriage, and cannot reside in the household of the Member.

Primary Member

The Primary Member is Member who completed the Membership application.

Program

The different Programs offered through a health share Membership. At OneShare Health, this includes the Catastrophic and Classic Programs.

Provider

A Physician, Practitioner, Specialist, Facility, or Hospital that provides any type of medical care or any other individual authorized by his or her state and performing within the scope of his or her practice as defined in state law.

Rehabilitation Facility

A facility licensed under state laws to provide intensive rehabilitative services. An inpatient Rehabilitation Facility means a free-standing facility or a unit of a Hospital, providing coordinated multidisciplinary physical restorative services to inpatients under the direction of a Physician knowledgeable and experienced in rehabilitative medicine.

  • A Rehabilitative Facility must meet all the following requirements:
  • It provides treatment and care for ill and injured persons on an inpatient basis.
  • It provides 24 hours a day service by registered graduate nurses (RNs).
  • Rehabilitation Facility includes a unit of a Hospital with beds set up and staffed and specifically designated for rehabilitative medicine.
  • It is not an institution, or any part used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction
Skilled Nursing Facility

A free-standing facility or section or wing of a Hospital, operated as part of a Hospital, duly licensed under applicable law as a Skilled Nursing Facility, providing Skilled Nursing Care 24 hours per day. Delivered by licensed graduate registered nurses (RNs) or unlicensed personnel supervised by RN’s, with such care directed or supervised by one or more Physicians.

Specialist

A licensed Physician who is qualified by advanced training and certification by a specialty examining board to limit his or her practice. A Physician cannot be the Member or a relative of the Member by blood or marriage and cannot reside in the household of the Member.

Specialist Visit(s)

Non-Surgical Services provided by a specialist provider for the diagnosis, treatment, management of an Eligible Illness or Injury.

Statement of Beliefs

A set of commonly held ethical or religious beliefs that unifies Members of a Health Care Sharing Ministry (HCSM) like OneShare Health.

Surgery

The branch of medicine that employs operations in the treatment of disease or Injury. Surgery can involve cutting, abrading, suturing, or otherwise physically changing body tissues and organs.

Smart Virtual Care (Telemedicine)

Smart Virtual Care (Telemedicine)5 uses AI and population health data to streamline and optimize your virtual visit. Through the Clever HealthTM App, Members experience greater convenience, faster visit times, more accurate diagnoses, additional Prescription Discounts, and 24/7 access to mental health chat resources.

Urgent Care

Medical care received for a sudden illness or injury that is not Life-Threatening or Life-Altering but does require immediate care to avoid severe pain, suffering, or complications.

Urgent Care Facility

Walk-in clinic focused on the delivery of ambulatory care in a dedicated medical Facility outside of a traditional Emergency Room.

Visit Fee

The amount that a Member is responsible for paying to the Provider of medical services for a specific visit before the Medical Expenses for the visit are Eligible for Sharing under the Program.

Waiting Period

The amount of time you must wait until your medical needs become Eligible for Sharing. At OneShare Health, unless otherwise stated, there is a 90-Day Waiting Period6 for any medical expenses other than for Accidents, Injuries, Acute Illnesses, or Immunizations, unless stated otherwise in the Eligible Sharing Descriptions and Limits.

 

1 Review Membership Guide for full details, waiting periods, pre-existing limitations, limits and ISA for all Sharing Services.
2 Mental Health Support is not owned or operated by OneShare Health.
3 Out-of-Network Providers and Facilities may bill the Members for the difference between the billed charges and the Program’s allowed amount, which may result in increased Member Sharing Responsibility.
4 Smart Virtual Care (Telemedicine) is not owned or operated by OneShare Health, LLC but made available to OneShare Members by Clever Health™.
5 There is a 180-Day Waiting Period for Classic Basic and Classic Enhanced Programs.