Medical costs are shared on a per person, per incident basis for illnesses or injuries incurring medical expenses after the Membership effective date when medically necessary and provided by or under the direction of licensed physicians, osteopaths, urgent care facilities, clinics, emergency rooms, or hospitals (inpatient and outpatient), or other approved providers of conventional or naturopathic care. Medical expenses eligible for sharing include, but are not limited to, home health care, physician and hospital services, emergency medical care, medical testing, imaging, ambulance transportation and prescriptions, unless otherwise limited or excluded by our Sharing Guidelines.

Total bills incurred must exceed an Annual Unshared Amount to be eligible for sharing (see VI.C.1.). A Medical Expense Need is any medically diagnosed condition for which one received medical treatment and incurred medical expenses from the same diagnosis. All medical bills related to the same diagnosis are considered as part of the same incident. Such expenses must be submitted for sharing in the manner and form specified by America’s HealthShare. This may include, but not be limited to, standard industry billing forms (HCFA 1500 and/or UB 92) and medical records.

Members share medical expenses such as:

1. Alternative and/or Integrative Treatments
   Alternative and/or Integrative Treatments are eligible for Sharing if such treatment meets the following criteria:
   1. It is prescribed by a Physician;
   2. It is prescribed for a medically diagnosed condition;
   3. It is deemed safe;
   4. It has peer reviewed evidence to support the treatment of the diagnosed condition; and
   5. It is presented for prior approval to America’s HealthShare, if required by Section VI.F.
2. Ambulance Service
   Emergency land or air ambulance transportation to the nearest medical facility capable of providing the Medically Necessary care to avoid seriously jeopardizing the Sharing Member’s life or health. However, the additional expense for transportation to a facility that is not the nearest facility capable of providing Medically Necessary care is not eligible for Sharing.
3. America’s Care CardSM
   America’s Care CardSM is discount program, offered by Careington International Corporation, that is available to Members. The America’s Care CardSM provides access to Telehealth and discounts on Eye care and Dental Care. The America’s Care CardSM is not an insurance program. Melita is not affiliated with Careington International Corporation. Information on the America’s Care CardSM is available at americascarecard.com.
4. Braces
   New and replacement braces of the leg, arm, back, or neck. Replacement braces are eligible for Sharing if there is sufficient change in the Sharing Member’s physical condition to make the current device no longer functional.
5. Cosmetic Procedures
   Cosmetic care and treatment provided for disfiguration caused by amputation, disease (including acne), accident, breast reconstruction following a mastectomy, or cranial protheses (wigs) for hair loss due to radiation or chemotherapy are eligible for Sharing. All other elective cosmetic treatment, including, but not limited to, pharmacological regimens; nutritional procedures or treatments; plastic surgery; salabrasion, chemosurgery, and other such skin abrasion procedures associated with the removal or revision of scars, tattoos, or actinic changes are not eligible for Sharing.
6. Direct Primary Care (DPC)
   Direct Primary Care monthly fees are eligible for Sharing up to $375 per year for a single membership, $750 per year for a couple membership, and $1250 per year for a family membership.
7. Eating Disorder
   Treatments for eating disorders are eligible for Sharing under the Mental Health Services.
8. Emergency Room Visits
   Emergency room services for stabilization or initiation of treatment for a medical emergency or condition provided on an Outpatient basis at a Hospital, Clinic, or Urgent Care Facility, including when Hospital admission occurs within twenty-three (23) hours of emergency room treatment. Healthcare Services at an emergency room are not eligible for Sharing if the Healthcare Services are not judged to be an emergency by normal standards of medical care and when less costly treatment was available by taking reasonable measures to seek such care.
9. Fertility
   Expenses for fertility treatments relating to the restoration or healing of the reproductive system in order to support procreation in the marital act.
10. Home Healthcare
    Skilled care services at home by a Home Healthcare agency for each related Incident provided such home care reduces the expected medical expense and replaces Hospital or nursing home services.
11. Hospice Care
    Hospice Care to include respite and/or comfort care is eligible for sharing but requires a Pre-Notification and is required to be renewed every 30 days as needed.
12. Hospital Charges
    Inpatient or Outpatient Hospital treatment or surgery for a medically diagnosed condition.
13. Hysterectomy
    Expenses related to a Hysterectomy if it is Medically Necessary. The Sharing Member must submit a Pre-Notification to America’s HealthShare prior to surgery, as stated in Section VI.F, unless it is a medical emergency.
14. Loss of Life Assistance
    If a Sharing Member under the age of sixty-five (65), die(s) after two (2) years of continuous monthly membership, financial assistance to the surviving family for loss of life expenses, including but not limited to funeral/burial expenses, will be provided by the Sharing Members according to the following scale.
    1. Primary applicant: Ten thousand dollars ($10,000).
    2. Dependent Spouse: Five thousand dollars ($5,000).
    3. Dependent Child: Three thousand dollars ($3,000).
    4. All Members must file with America’s HealthShare, at the time of enrollment, a directive in the form provided by America’s HealthShare identifying the recipient of any such loss of life assistance. If no directive is on file with America’s HealthShare, the financial assistance shall be paid to the Member’s estate, or pursuant to an order of the applicable Court with probate jurisdiction.
    5. A minor child (under the age of 18) enrolled by a parent or guardian and whose enrollment application is signed on behalf of such child by a parent or guardian, will be assisted at the same amount as a Dependent Child. Members who are sixty-five (65) years of age or older may choose to participate in the loss of life assistance at an additional fee on his/her suggested Monthly Contribution.
15. Maternity
    Medical expenses for Maternity, including, but not limited to, charges and expenses arising from Physician care, Hospital or birthing center admissions, attendance by midwives, or home deliveries accompanied by a midwife or Physician.
16. Medical Costs Incurred Outside the United States
    Charges for the care and treatment of a medically diagnosed condition when treatment outside the United States is financially beneficial or when traveling or temporarily residing outside the United States. Eligibility of such expenses are subject to all other provisions of the Guidelines. Medical billing is required to be submitted in English and US dollars.
17. Mental Health Services
    Expenses for counseling, drug and alcohol counseling, treatment, medication, and emergency hospitalizations are eligible for Sharing.
18. Natural Family Planning/Fertility Awareness-Based Methods
    Expenses for individual instruction and the initial supplies on approved fertility awareness-based methods, also known as Natural Family Planning. Such approved methods include, but are not limited to, Creighton, Couple to Couple League, Billings, Family of the Americas, SymptoPro, and Marquette.
19. Naturopathic Care
    Expenses for naturopathic care.
20. Nutritional Counseling
    Nutritional counseling is eligible for sharing with America Well when diagnosed with a condition where nutritional counseling is medically indicated.
21. Organ Transplant
    Morally permissible organ transplants and expenses incurred in evaluation, screening, transportation of the organ, the candidacy determination process, organ transplantation, organ procurement, follow-up care, immuno-suppressant therapy, and re-transplantation. Expenses related to the donation of an organ are eligible for Sharing if the organ is for a Sharing Member.
22. Physical Manipulation (Chiropractic) or Physiotherapy
    Up to twelve (12) visits per Program Year for treatment of musculoskeletal disease or injury prescribed by a Physician.
23. Physical Therapy
    Up to twenty (20) visits per Program Year for physical therapy by a licensed physical therapist in accord with a Physician’s order to improve body function.
24. Prescription Drugs and Supplements
    Prescription drugs are eligible for Sharing through Drexi Pharmacy Sharing for retail prescription drugs based on the current formulary and co-share schedule. Drexi Pharmacy Sharing is a program offered by Advanced Medical Pricing Solution Services (AMPS).
25. Prosthetics
    Prosthetics and their replacement, if Medically Necessary.
26. Restorative Reproductive Medicine (RRM)
    Expenses for Restorative Reproductive Medicine, which includes evaluation, treatment, therapies, surgeries, education and supplies.
27. Sterilization Reversal
    Reversal of a tubal ligation or vasectomy limited to one reversal attempt only for the sole purpose of restoring the procreative end of the conjugal act.
28. Telehealth
    Healthcare Services provided through digital communication technologies to deliver healthcare services remotely.
    1. Healthcare Services from DialCare Telemedicine through the America’s Care Card are eligible for Sharing.
    2. Telehealth from Providers who have provided Healthcare Services to the Member are eligible for Sharing.
29. Therapies
    Other therapies such as occupational, respiratory, cardiac rehabilitation, biofeedback and speech therapy by a licensed therapist in accord with a Physician’s order to improve function are eligible up to twenty (20) visits per Program Year.
30. Wellness Visits
    Charges for one (1) wellness exam or physical per Program Year are eligible for Sharing, before applying the Annual Unshared Amount, and include but not limited to screening labs (CBC, CMP, lipids, hemoglobin A1c, vitamin D and CRP). Sharing Members in the first two (2) years of life have seven (7) well-child visits for the first year and three (3) well-child visits for the second year eligible for Sharing. Other screening services including pap smears/HPV testing, screening colonoscopies, Prostate-Specific Antigen (PSA), DEXA scans, and breast imaging (screening mammogram/thermography) may be eligible for sharing following the America’s HealthShare wellness policy.