OSH_member_glossary

OneShare Health’s Glossary of Health Share 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 Membership. 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, or request a paper copy of your Guidebook, please visit https://www.onesharehealth.com/member-guidebook.

Term Definition
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 is the direct cause of a loss is Eligible for Sharing, occurring after the Member’s Effective Date.
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.
Behavioral / Mental Health Full range of mental, emotional well-being, and developmental challenges.
Behavioral Health / Member Assistance Program (MAP) The Behavioral Health / Member Assistance Program (MAP)2 is available to Members of the Catastrophic, Classic, and Complete Programs. Through our partners at IBH Solutions, the Behavioral Health / Member Assistance Program (MAP) provides innovative, technology-based tools and Work-Life treatments for substance abuse, behavioral health, and wellness engagement through the following services and more:
  • Confidential Counseling
    • Up to four (4) face-to-face, video, or telephonic counseling sessions for relationship and family issues, stress, anxiety, and other common challenges.
  • 24-Hour Crisis Help
    • Toll-free access for you or a family member experiencing a crisis.
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)3 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 Expenses The charge for a medical service or supply provided according to the terms of the Membership Guidelines, approved for sharing and whose sharing need amount does not exceed the Program Limits.
Eligible for Sharing Services that are Eligible to have their costs shared among OneShare Health Members, as well as the amount of this service that’s approved for sharing according to the terms in the Membership Guidelines, but not exceeding the Program Limits.
Emergency Room (ER) The Emergency Room Services you’ll receive for stabilization or initiation of treatment of a medical emergency for Life-Threatening or Life-Altering conditions; they are provided on an Outpatient basis at a Hospital.
Equivalent/Alternative Care Non-experimental health care treatment which may deliver care that is more cost-effective, less invasive, and within generally accepted medical practices, may be Eligible for Sharing. Prior approval is required from OneShare Health; see definition of ‘Pre-Certification.’
Explanation of Sharing (EOS) A statement sent to the Member and provider with an explanation of OneShare Health’s assignment to Member’s sharing of medical expenses submitted. In your EOS, you’ll find the charges from your health care Visit that have been shared by other Members, the charges applied to your Individual Sharing Amount, or ISA, and any other charges that were not shared that you are responsible for paying to your health care provider.
Facility Refers to any Facility that provides medical services on an Outpatient basis, whether a Hospital-affiliated or independent Facility.
First Health® Provider Network First Health® is an NCQA-accredited Provider Network that has strong provider relationships with more than 5,700 hospitals, over 120,000 ancillary facilities, and over 780,000 professional providers at over 1.5 million health care service locations across all 50 states! OneShare Health and First Health® have partnered together to bring you access to the best possible care, but we are still separate entities. When visiting a provider for a health care need, it is the Member’s responsibility to ask if the provider accepts OneShare Health through First Health® since it is First Health®, not OneShare, whose providers and facilities are contracted and tending to your specific health care needs. If you do not mention that you are a part of this network to your provider, it is possible they will not accept OneShare Health.
Guidelines The terms Guidelines, Sharing Guidelines, and Membership Guidelines all refer to the Membership Guidelines, as used in your Membership Guidebook.
Healthcare Bluebook An online resource where you can see pricing information on hundreds of procedures in your area, creating an opportunity for savings on your health care needs.
Health Care Sharing Ministry (HCSM) A ministry that facilitates the sharing of medical expenses among its Members and that meets the requirements under 26 USC Sec. 5000A(d)(2)(B)(ii). OneShare Health Members must hold to a common set of religious and ethical beliefs as stated in our shared Statement of Beliefs, by which our Programs operate.
Hospital An institution that is licensed, providing medical and surgical treatment and nursing care for the sick and injured, for the study of disease, and for the training of Physicians, nurses, and allied health care personnel. The institution provides 24-hours-a-day nursing services by Registered Nurses. It is accredited by the Joint Commission on Accreditation of Hospitals, sponsored by the AMA and the AHA. The requirement of surgical facilities shall not apply to a Hospital specializing in the care and treatment of mentally ill patients, provided such institution is accredited as such a Facility 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 provider licensed to practice medicine in his/her state.
Ineligible Not Eligible for Sharing.
In Network Refers to health care providers who are part of the First Health® Provider Network. OneShare Health and the First Health® Provider Network have partnered together to provide our Members with broader access to In Network health care professionals.
Inpatient Hospitalization Care of patients whose condition requires admission to a hospital. At OneShare Health, the term “Inpatient” includes any Facility admission, observation, or other confinement that lasts more than 23 hours.
Individual Sharing Amount (ISA) The amount a Member is responsible for paying before their medical expenses are Eligible for Sharing under the Program. ISA applies to Program Year.
Individual Sharing Responsibility (ISR) The percentage that a Member is responsible to share for medical bills after the ISA has been met, during the Program Year. After the ISA is met and Individual Sharing Responsibility is reached, Sharing Services are 100% Eligible for remainder of the Program Year, up to Maximum Limits.
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.
Maximum Limit Per Incident The Eligible amount to be shared for a specific medical incident or diagnosis under the terms of Membership Guidelines.
Maximum Reasonable Guideline For a Member using an Out-of-Network Provider or Facility, the Maximum Reasonable Guideline is the allowed charge made for necessary medical services, drugs, procedures, supplies, or treatment generally furnished for services of comparable severity and nature in the geographical area in which the services, drugs, procedures, supplies, or treatment is furnished. 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.
Medical Bill The medical expense(s) submitted to OneShare Health to be considered for Member Sharing.
Medical Expense(s) The charge(s) or expense(s) for medical services from a provider, Practitioner, or Facility for a Sharing Member, and the fees incurred by OneShare Health to reduce such charges or expenses.
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 Sharing Member participating by himself or herself; and/or their spouse, and/or a child(ren) enrolled by a parent or guardian, who certifies that he/she takes financial responsibility for the child(ren)’s sharing Membership and who signs the enrollment application on behalf of the child(ren).
Membership Program Year This is defined as the 12 months from your Effective Date; each additional Program Year will begin on the anniversary of your Effective Date. The Program Year is specific to you.
Not Eligible for Sharing Provider charges deemed Ineligible; or charges in excess of the Maximum Eligible Amounts as stated in the Sharing Guidelines. See also ‘Ineligible.’
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.
Out-of-Network When a health care provider is not contracted by your health program; this can sometimes result in higher prices for medical treatment. OneShare Health is proud to offer our Members the freedom to choose their own providers, even if that means they are Out-of-Network4. If you wish to nominate your provider to be contracted by First Health® Network, i.e. OneShare’s official Provider Network, you may do so on our website.
Outpatient When you receive Services at a Hospital but are not admitted as a registered overnight patient; this must be for a period of less than twenty-four (24) hours. This term can also be applicable to services rendered in a Free-Standing Facility or Hospital-Affiliated Facility.
Physician Office Visit Licensed Medical Professional/Physician Office Visits for the diagnosis, 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 and who holds the required licenses or degrees to perform those services, 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-Certification A process you or your health care provider follows to notify OneShare Health prior to receiving the specified medical services.
Pre-Existing Condition 24/24 Pre-Existing Condition means any sickness or Injury for which a Member received medical treatment, advice, care or services, including diagnostic measures, took prescribed drugs, or showed signs and symptoms, whether treated or not, within 24 months before the Member’s Effective Date of their Program. Eligibility for a Pre-Existing Condition has a 24-month Waiting Period.
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 the oldest Member enrolled and is responsible for payment of the Monthly Contribution Amount.
Program The different Programs offered through a health share Membership. At OneShare Health, this includes the Catastrophic, Classic, and Complete Programs.
Provider Network The list of the doctors, other health care providers, and hospitals that a program has contracted to provide medical care to its Members. First Health® Provider Network is the official Provider Network of OneShare Health.
Rehabilitation Facility Is 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 who is knowledgeable and experienced in rehabilitative medicine. A Rehabilitative Facility must meet all of the following requirements:
  • It provides treatment and care for ill and injured persons on an Inpatient basis.
  • It provides 24-hours-a-day services 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.
Shared Services The types of medical needs shared by Members, and how OneShare Health functions to facilitate that sharing.
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.
Telemedicine (by DialCare) The provision of health care remotely by means of telecommunications technology5. At OneShare Health, Telemedicine by DialCare is a modern, easy-to-use solution for non-Life-Threatening ailments and general care. Using your computer, tablet, smartphone, or other handheld device, you and your family can speak to state-licensed doctors 24 hours a day, 365 days a year, from anywhere. Note: MA residents have access to Teledoc, instead.
Urgent Care Services provided by a licensed Urgent Care Facility for the diagnosis, treatment, or management of an Eligible Illness or Injury serious enough that a Member would seek care right away, but not so severe as to require Hospital Emergency Room care.
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 This is the fee you pay for specified services by a health care provider as outlined by the Membership Guidelines. After the Visit Fee, Eligible Expenses are Shared at 100%. Visit Fees are per Visit.
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 The Behavioral Health/Member Assistance Program (MAP) is not owned or operated by OneShare Health and is not a sharing service but is made available to Members by Integrated Behavioral Health (IBH). We do not recommend or endorse any services, procedures, opinions, or consultations provided, and you assume all responsibility in connection with utilizing these services. Nothing available through the OneShare Health or Behavioral Health/Member Assistance Program site, or its services, is intended to be and must not be taken to be the practice of behavioral advice, or counseling care from OneShare Health. The MAP is available to Members of the Thrive and Route Programs.
3 Dependents of the Summit Program age off at 26.
4 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.
5 Massachusetts Members do not have access to DialCare, rather Teledoc.
6 There is a 180-Day Waiting Period for Classic Basic and Classic Enhanced Programs.