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Program Sharing Details for the
Healthy Life EasyShare Programs
I. General Sharing Requirements,
Restrictions, Limitations & Maximums
Total eligible needs for sharing among the Members are limited as set forth in this section, or elsewhere
in these Guidelines, and as may be indicated in writing to the individual Sharing Member from time-to-
time.
i. Waiting Period Prior to Sharing Eligibility.
The following waiting periods apply before Medical Expense Needs may become eligible for sharing
through this Universal HealthShare EasyShare Programs:
1. For a member who has been a Sharing Member continuously for at least twelve (12) months prior to
conception, medical expenses for Maternity are eligible for sharing, subject to the applicable Annual
Non-Sharable Medical Amount;
2. There is a 180-day waiting period before any Medical Expense Need for Cologuard testing may be
eligible for sharing;
3. There is a 30-day waiting period before any Medical Expense Need for Preventive Care including an
Annual Routine Physical or Well Child Exam may be eligible for sharing; and
4. There is a 90-day waiting period before any other Medical Expense Need may be eligible for sharing.
Note: This 90-day waiting period does not apply to sharing eligibility for Telemedicine, Primary Care,
Urgent Care, or Specialty Care visits or diagnostic testing, in-office procedures, and laceration repair
that take place during the visit, however, the waiting period does apply to Imaging and office based
surgical procedures.
ii. Annual Non-Sharable Amounts for Medical Expenses.
The EasyShare Programs have no annual Non-Sharable Amount; it is $0 for these Programs.
iii. Consultation Fees.
Members in the EasyShare Programs must always pay the following per-visit consultation fees, payment
of which will be due at the time of your visit. This portion of your fees are never eligible for sharing; they
are always your personal responsibility:
Member Consultation Fee
EasyShare50 EasyShare25
Telemedicine Consultation $0 $0
Primary Care Physician Visits $25 $40
Pediatrics Visits $25 $40
Routine Annual Physical/Well Child Exam and
Preventive Care Visits (including Immunizations)
$25 $40 UHFR093021E100121 Page 103
Specialty Physician Visits $50 $75
Urgent Care Physician Visits $75 $75
The EasyShare Programs allow for immediate sharing for Primary Care, Specialty Care, Pediatric, and
Urgent Care office visit charges, (the 90-day waiting period does not apply to these office visits).
Preventive Services have a 30 day wait period. You must pay a Consultation Fee for each visit; this fee
will be due at the time of your visit. After your payment of the Consultation Fee, the remaining portion of
the physician charges for the office visit only will be eligible under this sharing category. Charges other
than the actual | null | null | null | null | null | null | null | null | null | null | null | null | null |
null | Office Visit fee billed for physician services from that visit, such as testing, screening,
imaging, and procedures, may be sharable if applicable, subject to requirements and limitations. (If
multiple visits are required for an immunization that is eligible for sharing, the Member Consultation Fee
will apply to the initial visit and the cost of the immunization and the subsequent office visit to complete
the immunization will all be eligible for sharing.)
If imaging is done both without and with a contrast agent, that is considered two separate imaging series.
Similarly, if imaging is done on two different body parts (e.g., head and leg), that is considered two
separate imaging series.
All outpatient CT Scan, MRI, and X-Ray imaging have a 90-day waiting period and sharing eligibility is
limited to two such imaging services per year. These services are sharable only with a physician
prescription and must be procured at a free standing in-network diagnostic center and not from a hospital
unless received as an admitted patient. For eligible imaging services received other than from a hospital,
EasyShare limits sharing to not more than $400 per imaging series for CT scans and MRIs and $250 per
imaging series for x-rays with the member always responsible for any amount above that limit. Sharing is
subject to the annual program limits of EasyShare inclusive of any other eligible, sharable medical
expenses incurred throughout the Program Year.
Sharing expenses for Ambulance or Emergency Room services are only intended for medical conditions
that are life threatening or could seriously jeopardize the health of the individual and only when the injury
or illness results in an in-patient hospital stay. If eligible, EasyShare limits sharing for eligible emergency
services to not more than $1,000 per incident. All emergency and transportation-related expenses in
excess of $1,000 are always the responsibility of the member.
iv. Annual Sharing Limits.
There is an annual limit on the total amount of medical expenses that may be shared for any individual
Member in the EasyShare Program (“Annual Sharing Limit”) inclusive of any other eligible sharable
medical expenses incurred throughout the Program Year. The Annual Sharing Limits that establish the
maximum sharable amounts for any member in each EasyShare Program are as follows:
Annual Combined Program
Maximum
Routine Annual Physical, Well
Child Exam, and Preventive
Care Combined Sharing Limit
for Standard Programs
EasyShare50 $50,000 $500 maximum,
per member per year
EasyShare25 $25,000 $500 maximum,
per member per year UHFR093021E100121 Page 104
v. Lifetime Sharing Limits.
The maximum amount of lifetime sharing available for any EasyShare50 member is $500,000 and the
maximum amount of lifetime sharing available for any for | null | null | null | null | null | null | null | null | null | null | null | null |
null | null | EasyShare25 member is $250,000.
vi. Per Medical Incident Sharing Limits.
There is a limit on the total amount of medical expenses that may be shared for each Member in
connection with any Medical Incident (as defined herein), inclusive of all inpatient and outpatient Facility
and Professional expenses related to that Medical Incident.
The per Medical Incident sharing limit applicable for the EasyShare50 Program is as follows:
Service
# of
visits/incidents
Eligible for Sharing Member Pays
Inpatient Hospitalization 10 days Up to $3,000 per day
for room and board
Any charge above
the sharable limit
Inpatient and Outpatient
Surgery
2 procedures per
year
Up to $3,000 per
incident
Any charge above
the sharable limit
Emergency Room 2 visits per year Up to $1,000 per
incident
Any charge above
the sharable limit
Ambulance 2 incidents per
year
Up to $500 per incident Any charge above
the sharable limit
CT Scan 2 imaging series
per year
Up to $400 per imaging
series
Any charge above
the $400 per
imaging series
MRI 2 imaging series
per year
Up to $400 per imaging
series
Any charge above
the $400 per
imaging series
X-Ray 2 imaging series
per year
Up to $250 per imaging
series
Any amount above
$250 per imaging
series
The per Medical Incident sharing limit applicable for the EasyShare25 Program is as follows:
Service
# of
visits/incidents
Eligible for Sharing Member Pays
Inpatient Hospitalization 10 days Up to $2,500 per day
for room and board
Any charge above
the sharable limit
Inpatient and Outpatient
Surgery
2 procedures per
year
Up to $2,500 per
incident
Any charge above
the sharable limit
Emergency Room 2 visits per year Up to $1,000 per
incident
Any charge above
the sharable limit
Ambulance 2 incidents per
year
Up to $500 per incident Any charge above
the sharable limit
CT Scan 2 imaging series
per year
Up to $400 per imaging
series
Any charge above
the $400 per
imaging series
MRI 2 imaging series
per year
Up to $400 per imaging
series
Any charge above
the $400 per
imaging series UHFR093021E100121 Page 105
X-Ray 2 imaging series
per year
Up to $250 per imaging
series
Any amount above
the $250 per
imaging series
The EasyShare Programs share the actual charges of Room and Board and procedures up to the
maximum per-day or per-incident limit, inclusive of any other eligible, sharable medical expenses incurred
that day.
Emergency Room and Ambulance cost sharing for the EasyShare Programs are subject to the 90-day
waiting period and are limited to a maximum of two incidents per year. Emergency Room and Ambulance
expenses are only available for sharing for medical conditions that are life threatening or could seriously
jeopardize the health of the individual by seriously impairing bodily functions or by causing serious
dysfunction of any bodily organ or part, and if the illne | null | null | null | null | null | null | null | null | null | null | null |
null | null | null | ss results in an in-patient hospital stay.
Inpatient and outpatient hospital and surgery have a 90-day waiting period for the EasyShare Programs.
All outpatient CT Scan, MRI, and X-Ray imaging for the EasyShare Programs have a 90-day waiting
period and are sharable for up to two imaging series per year in each category, and only with a
physician’s prescription. Imaging services must be procured at a freestanding, in-network diagnostic
center, unless received as an admitted patient or performed in connection with an outpatient or
ambulatory surgical center procedure, in the same facility where the procedure is being performed, and
on the same day as the procedure is performed.
vii. Annual Visits & Hospitalization Sharing Limits
Sharing is limited to a maximum number of visits/days/incidents per Program Year for each Member, as
follows:
Type of Visit or Therapy Session
Max. Number of Visits/Days/Incidents Per Program
Year Eligible for Sharing
Annual Routine Physical or Well Child Exam 1 visit per Program Year
Primary Care, combined with Pediatrics 4 visits in total for any combination of Primary Care and
Pediatrics (Annual Physical or Well Child Exam does not
count towards this limit) per Program Year
Urgent Care 2 visits per Program Year
Specialty Care 2 visits per Program Year
Inpatient Hospital Care 10 days per Program Year
Surgery (Inpatient or Outpatient) 2 procedures per Program Year
Emergency Room 2 visits per Program Year
Ambulance 2 incidents per Program Year
CT Scan 2 visits/series per Program Year
MRI 2 visits/series per Program Year
X-Ray 2visits/series per Program Year
For the EasyShare Programs, once the 90-day waiting period has passed, the following portions of
Eligible Medical Expenses are generally sharable at the actual amount charged up to the maximum day
or incident limit amounts inclusive of any other eligible, sharable medical expenses incurred throughout
the Program Year based on the following schedule, subject to all exclusions, restrictions and limitations
set forth in these Guidelines: UHFR093021E100121 Page 106
Type of Medical Need
EasyShare Per-incident Limit 1
Maximum Number of
Days / Incidents 1
Type of Medical Need EasyShare50
Per-Incident Limit 1
EasyShare25
Per-Incident Limit 1
Maximum Number of
Days / Incidents 1
Hospitalization Room & Board $3,000 $2,500 10
Inpatient or Outpatient Surgical
Procedures
$3,000 per surgical
procedure
$2,500 per surgical
procedure
Two Surgical
Procedures per
Program Year
Emergency Room2 $1,000 $1,000 2 incidents per
Program Year
Ambulance 2
$500 $500 2 incidents per
Program Year
CT Scan 3
$400 $400 2 per Program Year
MRI 3
$400 $400 2 per Program Year
X-Ray – Non-Hospital Facility 3
$250 $250 2 per Program Year
1. EasyShare pays a maximum annual per member amount ($50,000 for EasyShare 50 and $25,0 | null | null | null | null | null | null | null | null | null | null |
null | null | null | null | 00 for
EasyShare25) for all services combined. The table above represents the amounts shared for
particular incidents and any limitations specifically related to such incidents. The program shares the
actual charges of room and board up to the maximum listed in the chart above per day. In addition,
for surgical procedures, the program shares the actual charges up to a maximum amount listed
above per incident. The member is responsible for any amounts above the EasyShare amounts. In
services where the member is responsible for the consultation fee EasyShare shares the balance up
to program maximums.
2. Emergency room cost sharing and ambulance limited to a maximum of 2 incidents per year.
Emergency room/ambulance are only available for sharing if the intended for treatment of medical
conditions that are life threatening or could seriously jeopardize the health of the individual and if the
illness results in an in-patient hospital stay, inclusive of any other eligible, sharable medical expenses
incurred throughout the Program Year.
3. All outpatient CT Scan, MRI, and X-Ray imaging have a 90-day waiting period and sharable only with
a physician prescription and must be procured at a free standing in-network diagnostic center unless
received as an admitted patient. For CT Scan, MRI, and X-Ray imaging in a non-hospital environment
EasyShare limits sharing to not more than$400 for CT Scan and MRI and not more than$250 for X-
Ray with the member responsible for any amount above that limit. These diagnostic procedures are
fully sharable if performed during an eligible, sharable inpatient stay and for an inpatient surgical
procedure.
viii. Sharing Amounts/Percentages.
Sharing Percentages are not applicable to the EasyShare Programs. Sharing amounts/limits are shown
above in section V, subsection vii, Per Medical Incident Limits.
II. Medical Expense Sharing
Medical costs are shared on a per person per Medical Incident basis for illnesses or injuries incurring
medical expenses after your Effective Date that were medically necessary and provided by or under the
direction of licensed Physicians, Hospitals or other licensed medical Facilities, or approved Practitioners.
A Medical Incident means a medically diagnosed condition and all medical treatment(s) received and UHFR093021E100121 Page 107
medical expenses incurred relating to such diagnosis. All medical bills of any nature relating to the same
diagnosis are part of the same Medical Incident. Medical expenses eligible for sharing include, but are not
limited to, physician and hospital services, emergency medical care, medical testing, x-rays, emergency
medical transportation and prescription medications provided by a Hospital during an admission, unless
otherwise limited or excluded by these Guidelines. Total bills incu | null | null | null | null | null | null | null | null | null |
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