Health sharing plans – also known as medical cost-sharing plans – are a much more affordable alternative compared to the cost of an unsubsidized Affordable Care Act health insurance policy. But how do health share plans manage to pay for a surgery?
Health sharing plans frequently have some restrictions when it comes to sharing costs for surgeries soon after enrollment.
Every health share plan is different. This blog will be an in-depth discussion of how healthshare plans share costs related to surgeries – especially for new members.
Medically necessary surgeries are generally shareable with healthsharing plans, except for new members.
We’ll also explore exact surgery waiting periods in several of the top health share plans available nationwide, including Universal Healthshare, Sedera, Zion, HSA SECURE, netWell Healthshare, OneShare Health, the CARE+ plan, and Prosper, Sedera, Medi-Share, Altrua, and Zion.
If you recently enrolled in a healthsharing plan listed here, or you’re considering it, and you expect to have surgery in the near future, you should know exactly what your health share plan’s policy is.
Medical Cost Sharing
With at least 1.7 million health share plan members nationwide, the popularity of medical cost sharing is exploding from coast to cost.
It’s easy to see why: if you don’t get a subsidy under the Affordable Care Act, the average cost of a full-fledged health insurance plan over the exchanges is more than $1,200 per month.
The same family can typically purchase a health sharing plan for 40 to 50 percent of that amount per month – saving thousands of dollars every year.
The savings, however, come with some tradeoffs. The most significant of which is waiting periods for surgeries and pre-existing conditions.
What is a Surgery Waiting Period?
Surgery waiting periods are a common feature in health sharing plans.
The term refers to a designated period during which new members must wait before they can receive coverage for certain surgical procedures. These waiting periods serve several purposes:
- Cost control
- Fraud prevention
- Encouraging long-term commitment to the healthsharing community.
Restrictions on surgeries for new members and waiting periods on preexisting conditions help health share organizations limit the risk of adverse selection.
This occurs when people don’t sign up for a health sharing or health insurance plan until they know they have a health problem.
Adverse selection is very expensive to health plans. Limiting it helps keep costs down for all members.
Considering Pre-Existing Conditions and Surgery Needs
Health sharing plans potentially provide lots of savings, but they aren’t for everyone.
If you have significant pre-existing conditions or you expect surgery soon, you may be better off in a traditional health insurance plan.
Waiting periods for surgeries related to pre-existing conditions may vary, ranging from 12 to 36 months, depending on the healthsharing plan.
In most cases, surgeries to treat injuries from accidents that occur after you enroll in a health sharing plan are shareable. The health sharing plan will help you pay for these emergency surgeries that could not have been foreseen at the time you enrolled.
But elective or scheduled surgeries are generally subject to a waiting period before the health share plan will consider those costs shareable.
A few general notes:
- Most healthshare plans will not share costs for cosmetic surgery, except to correct disfiguration from an injury or illness, or arising from medical treatments of diagnosed conditions. Examples include surgeries to correct disfigurement from amputation, mastectomy, disease or accident.
- These generally include things like reconstructive mammoplasty or similar procedures performed by a general surgeon.
- Sex change/gender reassignment surgeries are generally not shareable.
- Certain procedures may require a second opinion.
Preauthorization
Non-emergency surgeries will typically require pre-authorization.
This requirement is not necessarily restrictive. This allows the healthshare plan’s “concierge service” to help you shop around for quality providers who can provide the surgery at a decent price.
Preauthorization also gives the health share plan’s negotiation desk to help you negotiate the cost of the procedure with your chosen health care providers – reducing the cost for everyone in the plan.
Selecting Providers
Most health sharing plans allow members a great deal of latitude when it comes to selecting health care providers.
This sets health share plans apart from most traditional health insurance plans sold under the Affordable Care Act. Most of those plans are HMOs and PPOs, which restrict benefits for any non-emergency care you get without a referral, in the case of HMOs, or for any non-emergency treatment you get from a provider who isn’t part of your plan’s narrow network.
However, some health share plans do have some preferred providers. So you should definitely check your plan’s guidelines, or call your plan’s concierge service for guidance on selecting providers and facilities for planned surgeries.
Compare Pricing on the Best Insurance Plans Available
Surgery Policies at Leading Health Sharing Organizations
HSA SECURE
HSA SECURE is unique in that it is the only major healthsharing plan on the market that also includes a high deductible health plan (HDHP).
As a result, otherwise qualified members are eligible to make pre-tax contributions to health savings accounts.
To enroll in HSA SECURE, you must own a business or have verifiable income from self-employment or as an independent contractor.
Shareable amounts for pre-membership medical conditions are as follows:
- Year One: $0 (waiting period)
- Year Two: $25,000 maximum per sharing request
- Year Three: $50,000 maximum per sharing request
- Year Four: $125,000 maximum per sharing request
After four years of membership, expenses related to pre-membership medical conditions will be shareable up to a maximum of $125,000 in a 12-month period. The shareable maximum resets each membership year.
The HSA SECURE Plan has a 24-month lookback period for pre-membership medical conditions.
- Cataract surgery is subject to a one-year waiting period before it is shareable.
- Expenses related to cosmetic surgery are shareable only for disfigurement due to a shareable injury or illness.
- Joint replacement treatment and surgery for degenerative arthritic conditions may be shareable beginning in the second year of membership.
- Organ transplants are shareable; however, they are subject to limitations for pre- membership medical conditions.
- Elective sterilization, such as tubal ligation and vasectomy, is not shareable.
Click here to learn more about HSA SECURE and get a free, personalized quote.
If you don’t have self-employment income and don’t own a business, but you’re still interested in a low-cost healthsharing plan from the same organization, you can also consider the CARE+ plan, listed below.
EXAMPLE
Here’s an example of how the HSA SECURE plan would treat a common surgical procedure: a total knee replacement.
A typical uninsured cost of a total knee replacement might be around $23,000. Costs may vary widely depending on your location and the provider and facility. But $23,000 would be very much within the typical range.
If the knee replacement isn’t attributable to an unforeseeable accident, the health share plan would treat it as a pre-existing condition.
If you are a brand-new HSA SECURE plan member, the plan would not share these costs. It would fall within the first year of the waiting period.
You would be responsible for all costs related to the knee replacement surgery, including follow-up costs, post surgery hospitalization, and treating complications.
If you had been a member for more than 12 months but less than 25 months, HSA SECURE would share the costs, up to $25,000.
That would be enough to pay for the surgery, though you would still be responsible for your own annual member contribution.
If you needed a more expensive surgery, however, such as a kidney replacement, which costs up to $250,000 and more, the plan would look to see if the surgery was for a pre-existing condition.
If you were symptomatic for or received treatment for kidney disease, renal failure, or any contributing medical conditions that could cause your kidney issue within 24 months prior to enrolling, the plan would consider your kidney issue a pre-existing condition.
They would then apply the pre-existing condition waiting period to any related kidney surgeries, including a transplant.
So assuming your transplant costs amount to $250,000, you would have to pay for all costs in year one. The plan would not share any costs.
In year two, the plan would still share just $25,000, minus your annual member contribution. You would be responsible for the remaining $225,000.
If you had the transplant In year three, the plan would share up to $50,000 of your transplant costs.. You would be responsible for the remaining $200,000, including your member contribution.
If you had the transplant in year four, the HSA SECURE Plan would share up to $125,000, minus your annual member contribution. You would be responsible for the remaining $125,000.
In year five and thereafter, you would be responsible for your annual member contribution. The plan would pick up all your transplant/surgery costs after that.
netWell
netWell’s “Advantage” and “Elite+” plans generally share surgery costs, subject to the following stipulations:
- Surgeries require pre-authorization except for emergencies.
- An initial 90-day waiting period from the member’s effective date applies.
- Pre-authorization is required for any Surgery services to be considered eligible for sharing by the membership.
- Exception in the case of an eligible acute injury or illness that is life-threatening or life-altering.
- A second surgery may be eligible for sharing 24 months from the date of the first surgery unless approved as part of the original treatment plan or within 15 days for any medical complications from the initial surgery.
- Eligible surgery costs are shared at 100% of the allowed amount, once the Member Commitment Portion (MCP) has been met.
- Bariatric surgery costs are not shareable.
- Breast augmentation, implant, or reduction surgery costs are not shareable.
- Elective cosmetic surgeries are not shareable.
- Cataract surgery is not shareable.
- Female or male elective sterilization surgery is not shareable.
- Congenital birth defects are not shareable.
- netWell does not share costs related to medical tourism.
netWell’s Advantage plan is designed to share primary care costs only and does not share surgery costs.
Of the two plan tiers that do include cost sharing for surgeries, the Elite+ plan is the most popular.
Click here to learn more about netWell and get a free, personalized quote.
EXAMPLE:
Here’s how the Elite + plan would calculate shareable surgery costs:
If You’re a brand new member, less than 90 days from your enrollment date, the netWell Elite + plan would not share any costs. You are still within the initial surgery waiting period for the plan. You’ll therefore be responsible for all costs, unless your surgery is attributable to an injury or accident occurring after your enrollment date that could not have been foreseen beforehand.
After 90 days, surgery costs are shareable, but must be pre authorized except in emergencies.
OneShare Health
Surgery costs are generally shareable after an initial 90-Day waiting period and after the Member’s initial responsibility is met.
OneShare Health also has a 24 month waiting period before costs related to pre-existing conditions become shareable, with a 24-month lookback period. This is one of the more lenient pre-existing conditions restrictions in the healthsharing industry.
Inpatient/Outpatient/Physician office surgery is eligible for sharing up to the maximum limit per incident.
If the surgery is the result of acute illness, accident, or life-threatening or life-altering emergency, then the initial 90 waiting period is waived.
OneShare Health generally shares medical costs up to a fair and reasonable percentage of what Medicare pays for the procedure.
Plan members should call OneShare at least 10 days prior to any scheduled surgeries for preauthorization and to allow OneShare to negotiate the best possible price.
OneShare does not share costs for cosmetic surgery, septoplasty, or weight loss surgery.
Click here to learn more about OneShare Health and get a free personalized quote.
EXAMPLE:
If you are a brand new member and you need a $23,000 total knee replacement, you would probably have to wait up to two years before your knee replacement costs become shareable.
EXCEPTION: If the knee replacement was due to an injury or accident that occurred after your effective membership date that could not reasonably have been foreseen, then those costs would be shareable, subject to your annual Member Responsibility Amount.
With most other plans, however, you may have to wait as long as 36 months.
Once your surgery costs become shareable under the plan, and you have satisfied your Member’s Initial Responsibility amount for the year, OneShare Health will share your surgery costs – up to a percentage of the Medicare reimbursement rate for that procedure.
Preauthorization is required except in emergencies.
CARE+
CARE+ is a competitively priced alternative to HSA SECURE, run by the same healthsharing organization.
It does not enable members to contribute to an HSA. But other benefits are very similar to the HSA SECURE Plan.
The major difference is that HSA CARE+ is not a qualified HDHP, and does not cover certain preventative care services.
Members must wait 12 months before expenses relating to pre-existing conditions, including surgeries, are shareable.
After 12 months, the plan will share up to $25,000.
After 36 months, this amount increases to $50,000.
After year four, up to $125,000 in costs for pre-existing conditions are shareable.
- Cataract surgery is subject to a one-year waiting period before it is shareable.
- Expenses related to cosmetic surgery are shareable only for disfigurement due to a shareable injury or illness.
- Joint replacement treatment and surgery for degenerative arthritic conditions may be shareable beginning in the second year of membership.
- Organ transplants are shareable; however, they are subject to limitations for pre- membership medical conditions.
- Elective sterilization, such as tubal ligation and vasectomy, is not shareable.
Click here to learn more about the CARE+ Plan and get a free, personalized quote.
EXAMPLE:
The CARE+ covers pre-existing conditions and surgeries the same way that the HSA SECURE plan does.
Suppose you had just become a member, and two weeks later, you got a hip replacement, with a total cost of $35,000.
Normally, none of that cost would be shareable. You would be responsible for the entire cost, within the first year of membership.
The exception would be if you needed the hip replacement due to an accident or injury that occurred after you joined the CARE+ plan.
If you got the surgery in your second year of membership, however, you’d still have to cover your member responsibility amount that you selected. The CARE+ plan would share up to $25,000 after that. You would be responsible for the remaining amount.
So it’s still much better than nothing.
If you got the surgery in your third year, you’d have to pay your initial member responsibility amount for the year. After that, the CARE+ plan would cover the entire surgery cost.
Prosper
Prosper is a comprehensive program that compares well against netWell and OneShare.
General New Member Waiting Periods
- There is a 30 to 90-day waiting period for new members before most conditions qualify for sharing other than accidents.
- The waiting period does not apply to sharing eligibility for office and emergency room visits related to accidents, sickness, acute illness, and life-threatening emergencies.
Pre-existing Conditions
- When it comes to surgery waiting periods, Universal Healthshare implements a waiting period of 36 months for most pre-existing conditions.
- In the 2nd year of continuous membership, Universal may share up to $50,000.
- Some conditions, such as cancer, have a waiting period of up to 60 months.
- After the initial waiting period has expired, or if the surgery is for an accident that could not have been foreseen at the time of enrollment, Universal Healthshare will share costs for Inpatient or outpatient hospital treatment or surgery for a medically diagnosed condition only when such care or procedures cannot be performed in a non-hospital, ambulatory facility.
- They require pre-notification, except if admission to the hospital occurs within 23 hours of emergency room treatment for the same condition that required emergency room treatment.
Organ Transplants
- With Universal Healthshare, expenses related to an organ transplant are eligible for sharing only when a second opinion is received from a physician approved by Universal HealthShare.
- Pre-authorization is required.
- The physician rendering a second opinion must examine the patient and relevant medical records prior to surgery and must find that a transplant is medically necessary.
- The sharing member must pre-notify Universal HealthShare prior to surgery for referral to the second physician.
Click here to learn more about Universal Healthshare and get a free, personalized quote.
EXAMPLE:
Continuing with the $35,000 hip replacement example above:
Unless you need the hip replacement because of an injury or accident that occurred after your membership effective date, you would be responsible for the entire cost of the surgery for the first year.
After the first year, you’d be responsible for your initial member responsibility amount that you selected.
After that, Universal may share up to $50,000 in costs. You would be responsible for the rest.
Note: If the operation is due to cancer that was detected prior to you becoming a member, then Universal would not share those costs for 60 months, or five years.
The plan would share costs for treating other medical conditions. But cancer is subject to a 60-month waiting period. Universal Healthshare would likely not be a good choice for people with a history of cancer.
Sedera Health
For surgical procedures, Sedera Health typically applies a six-month waiting period from your membership date.
Mastectomy costs for cancer treatment are currently shareable at $20,000 per breast, plus 50% of costs above that amount, subject to the member’s initial unshareable amount.
Medically necessary breast reduction surgery costs are shareable up to 75%.
Cataract surgery costs are shareable up to $5,000 per eye.
Sedera also shares up to 75% of costs over and above the member’s initial unshared amount for preventative cancer surgeries. Sedera may be a good choice for those who have a genetic predisposition to cancer.
However, reconstructive surgery post-preventive surgeries/procedures and/or post-surgery hormone replacement are not shareable under Sedera’s plan.
Surgeries other than cataract surgeries require an expert 2nd opinion. If you submit the 2nd opinion at least 7 days prior to surgery, your initial unshared amount will be reduced by $250.
There’s a 36-month look-back period on most pre-existing conditions.
After your membership start date, costs related to treating pre-existing conditions, including surgery, are shareable as follows:
- Months 1-12: : Not sharable.
- Months 13 – 24: Shareable up to $25,000
- Months 25-36: Shareable up to $50,000
- Month 37: and beyond: Fully shareable
Members undergoing a mastectomy, reconstruction, or cosmetic procedure as a part of a pre-existing cancer diagnosis are subject to the Pre-existing Sharing Limitations.
Organ Transplants
Organ transplant surgery costs are generally shareable, subject to Pre-existing Condition sharing limitations and price negotiation.
Sedera may require proof of ineligibility or denial for public or nonprofit organ donor programs.
Click here to learn more about Sedera and get a free, personalized quote.
EXAMPLE:
Like the CARE+ and HSA SECURE plans, Sedera has a progressive, sliding scale of shareable costs.
If you need a $35,000 hip replacement done, you would be responsible for the entire cost for the first year after your membership effective date.
In Year 2, you’d have to pay your member responsibility amount. Sedera would share the rest of the cost, up to $25,000. You would be responsible for costs above that point, unless your hip replacement was due to an injury or accident that occurred prior to your membership.
In Year 3, you’d still have to pay your initial member responsibility amount. But since at that point Sedera’s guidelines say they will share up to $50,000, you would not have to pay anything for the rest of that year.
Again, however, if the surgery is attributable to cancer, there’s a much longer 60-month (5-year) waiting period before those costs become shareable.
Note also the different cost-sharing structures for mastectomies.
Sedera will also share costs for some surgeries that are designed to pre-empt a likely future cancer diagnosis. You’d have to pay your initial unshareable amount, plus up to 25% of the cost of these surgeries. Sedera would pick up the rest.
Sedera is one of the more generous plans when it comes to helping members pay for cancer-preventative surgeries. It is therefore a solid choice for those at elevated risk for developing cancer due to family history/genetics.
Medi-Share
Medi-Share only shares costs related to pre-existing medical conditions after at least 36 consecutive months of membership, up to $100,000 per member per year.
After 60 consecutive months of sharing, the per-member limit for pre-existing conditions increases to $500,000.
Cosmetic breast reconstruction after breast cancer is eligible for sharing for the affected breast and the non-affected breast if recommended for purposes of symmetry and only if the breast cancer is eligible for sharing. Revisions of initial breast reconstructions are ineligible for sharing except in cases of infection, necrosis or treatment of lymphoma.
Purely cosmetic procedures – including, but not limited to, breast augmentation, lift or reduction, body or facial contouring, scar revision, tattoo removal, electrolysis, cosmetic Botox – are not shareable.
Orthodontic/oral surgery costs are not shareable except to repair trauma within one year of the incident.
Vasectomies and tubal ligation surgeries are not shareable.
Sharing for injuries from motorcycle accidents is limited to $100,000.
Click here to read more about Medi-Share and get a free, personalized quote.
EXAMPLE:
If you need a hip replacement surgery that costs $35,000, not attributable to an accident, you would be responsible for all costs for the first three years.
After three years, you’d have to pay your initial member responsibility amount. Medi-Share would share the rest of your expenses, since the cost of the hip replacement falls under the Medi-Share sharing limits for years 3 through 5.
If you needed a more expensive procedure, such as a kidney transplant costing around $250,000, you would still be responsible for all costs for the first three years. If all your preparatory expenses and surgery happened you three years and a day after your membership effective date or later, here’s what would happen:
- You would be responsible for your initial member responsibility – an amount you selected when you enrolled in the Medi-Share plan.
- Medi-Share would share up to $100,000 in costs related to that hip replacement.
- You would be responsible for everything above that amount.
If you needed the kidney replacement and incurred all other related costs at least five years after your membership effective date, you will still pay your initial unshareable amount for the year.
After that, Medi-Share would share all the other costs, since the $250,000 price tag is well under their maximum shareable amounts after 60 months of continuous membership.
Altrua
Altrua only shares costs related to cancer treatment if you choose to enroll in the MyCare Cancer option.
Otherwise Altrua will not share cancer-related costs, including surgery.
Cancer costs are subject to a 90-day waiting period after your membership effective date.
The following procedures and services are also subject to an initial waiting period:
90 Days
- Ophthalmic surgical procedures
- Outpatient surgery, testing, and procedures (including pre-admission testing)
12 months
- Cataracts and Glaucoma Diagnostic Testing and Surgery
- Organ Transplants
Costs related to pre-existing limitations are subject to a waiting period of between two and five years. Some conditions are subject to an indefinite waiting period. That is, costs related to treating those conditions will not be shareable no matter how long you are a plan member.
Altrua has an unusual cost structure: Members are subject to two separate annual Member Responsibility Amounts. This could have an effect on how much your plan shares for surgery expenses.
CANCER
Altrua has an unusually long pre-existing condition lookback period of ten years, as well as a surgery exclusion of five years after membership effective date for pre-existing conditions.
If you selected Cancer Sharing as part of your MyShare membership, and you have been diagnosed with a specific type of cancer within the 10 year look back period, you’ll have a 5 year pre-existing limitation for testing and/or treatment… but only related to that specific cancer.
If you develop a different type of cancer, then the pre-existing condition waiting period would not apply. However, you’d still have a new member 90 day waiting period before those treatment costs for the new cancer would be shareable.
Click here to learn more about Altura and get a free, personalized quote.
EXAMPLE:
Altrua has different waiting periods for different pre-existing conditions.
So your out-of-pocket costs for surgery could be very different depending on the nature of your pre-existing condition.
Altrua is unusual in that cancer-related surgery costs are not shareable unless you elect the special MyCare Cancer option, which requires a higher monthly member contribution.
There’s a 90-day surgery exclusion in any case.
Altrua also allows members to select lower annual and lifetime sharing maximums. These reduce monthly contributions. But a low cap could also mean there’s not enough sharing capacity available to absorb more expensive surgical costs.
Example: Suppose you elect the MyShare Cancer option, and a top sharing benefit of $100,000. A few years later, you have a brain cancer diagnosis, and require a complicated surgery and course of treatment with expensive chemotherapy.
If the surgery and related treatment costs $200,000, you would have to pay your Annual Member Responsibility Amount for the year. Then Altrua would share up to $100,000.
You would still be responsible for the remainder.
If you did not select the MyCare Cancer option, you would be responsible for all costs.
If you had surgery for a condition within ten years prior to becoming a member, you would also face an exclusion period of up to five years for future surgeries related to that same condition. .
LEARN MORE
You can learn more about Altrua’s plans, as well as get more specifics on pre-existing conditions limitations and waiting periods, by contacting an HSA for America Personal Benefits Manager.
To get started click here to learn more about Altrua and get a free personalized quote.
Zion Health
Pre-membership medical conditions are subject to a four-year phased-in waiting period before expenses are fully shareable:
After the initial 12-month waiting period, during which costs for pre-membership conditions are non-shareable. The shareable amount increases every 12 months.
- Year One: $0 (waiting period)
- Year Two: $25,000 maximum per sharing request
- Year Three: $50,000 maximum per sharing request
- Year Four: $125,000 maximum per sharing request
After four years of membership, expenses related to pre-membership medical conditions will be shareable up to a maximum of $125,000 in a 12-month period. The shareable maximum resets each membership year.
Cataract surgery is subject to a one-year waiting period before it is shareable.
Expenses related to cosmetic surgery are shareable only for disfigurement due to a shareable injury or illness.
Organ transplants are shareable; however, they are subject to limitations for pre- membership medical conditions.
Elective sterilization, such as tubal ligation and vasectomy, is not shareable.
EXAMPLE:
Zion Health’s sharing guidelines for surgeries are the same as those for the HSA SECURE and CARE+ plans listed above.
Surgery costs related to pre-existing conditions are not shareable for the first 12 months. You are responsible for all costs.
However, if you need surgery because of an accident or injury that occurred after your membership effective date, you’d pay your Member Responsibility Amount that you selected when you joined the plan, and Zion Health would pick up the rest. This is true at any time during your membership.
In Year Two, Zion Health sharing will share up to $25,000 per sharing request, after you pay your Member Responsibility Amount for the year.
In Year Three, Zion will share up to $50,000.
In Year Four, Zion will share up to $125,000.
After Year Four, surgeries related to preexisting conditions are fully shareable.
Compare Pricing on the Best HealthShare Plans Available
What to Consider
If you anticipate needing surgery or if you have pre-existing conditions, you should absolutely take those into account when deciding whether to enroll in a traditional health insurance plan or a lower-cost health share plan.
While medical cost sharing can lead to substantial monthly savings, individuals with pre-existing conditions or expecting surgery should carefully assess their options.
For an individualized assessment and recommendation, contact one of HSA for America’s experienced Personal Benefits Managers.
HSA for America is recognized as the top national benefits broker when it comes to health sharing plans. And we are among a very few health benefits brokers who can speak to you about both health insurance and health sharing plans.
Just click here to make an appointment.
Conclusion
In conclusion, selecting the right health insurance option is a critical decision that requires careful evaluation of your unique healthcare requirements.
Click on any of the links provided to learn more about each individual healthshare plan, or make an appointment with a Personal Benefits Manager for personalized guidance and support.
Here are some additional articles on healthsharing programs: Best Healthshare Plans Comparison Guide 2023 | How Much Money Can Healthsharing Save? | Is a DPC Plan Right For You? Your 2023 Guide on Direct Primary Care Pros and Cons!
Here are some additional pages related to this article: Healthshare Plans | Complete Guide to Direct Primary Care (DPC)
Frequently Asked Questions About Health Sharing Plans and Surgery
How do health sharing plans generally pay for surgery?
Health sharing plans typically operate on a system of voluntary financial contributions from members who share similar beliefs and values. When a member requires surgery, the plan’s guidelines determine how much money will be shared to cover the cost of the procedure.
Guidelines address waiting periods, limitations, exemptions, exclusions, and preauthorization requirements for surgical costs.
Do health sharing plans have waiting periods for surgery?
Yes, many health sharing plans have waiting periods before coverage kicks in for surgeries. These waiting periods vary depending on the plan but can range anywhere from a few months to several years.
Some health sharing plans may impose pre-existing condition waiting periods. These waiting periods are designed to prevent individuals from joining the plan solely to receive immediate coverage for an already diagnosed condition.
Are there any restrictions on which surgeons or hospitals can be used with a health sharing plan?
While some traditional insurance networks restrict healthcare providers, most health sharing programs allow their members greater flexibility in choosing physicians and hospitals without being limited to specific care networks.
This is in contrast to traditional health insurance HMOs and PPOs, which have narrow care networks and restrict what they will pay for non-emergency care received out of network.
Is preauthorization required for surgical procedures with a health sharing plan?
Preauthorization is often required by health sharing organizations as it helps maintain control over costs while ensuring that recommended treatment is medically necessary.
What types of surgical procedures are commonly excluded under most health-sharing arrangements?
Health-sharing agreements usually exclude cosmetic surgeries, fertility treatments, gender reassignment surgeries, weight loss surgeries (unless deemed medically necessary), abortions of live fetuses, experimental or investigative procedures not yet proven effective by medical experts, and non-emergency dental procedures.
How would a cancer diagnosis affect my eligibility and coverage under a health-sharing arrangement?
Cancer treatment is usually covered by reputable faith-based sharing organizations; however, it is essential to review each program’s specific guidelines beforehand since individual policies may differ regarding eligibility criteria and monetary limits set aside for cancer-related procedures.
Are emergency surgeries exempt from surgical waiting periods in health sharing plans?
Yes, emergency surgeries resulting from accidents or acute illnesses are generally exempt from surgical waiting periods imposed by most faith-based sharing organizations. This ensures timely access to critical care without facing substantial delays or administrative hurdles.
Is there any flexibility regarding surgery waiting periods if my condition worsens during the waiting period on a health-sharing arrangement?
Unfortunately, most sharing organizations require adherence to their established waiting periods regardless of changes in your medical condition during that time period.
If you have a pre-existing condition that requires ongoing care, and there’s a risk your condition will deteriorate without care during any given health sharing plan’s surgery waiting period, you may be better off in a traditional health insurance plan.
Health insurance typically covers medically necessary surgery from the first day of enrollment and doesn’t have a surgical waiting period.
How long does it typically take to receive reimbursement or payment from a healthsharing plan for surgical procedures?
The timeframe for receiving reimbursement or payment following a surgical procedure may vary among different health-sharing organizations. It is important to review the policies and guidelines provided by each specific organization to understand their typical processing times and requirements.
Wiley is President of HSA for America. He believes that consumers should have choice and price transparency, so they can make the best healthcare decisions for their needs. Read more about Wiley on his Bio page.