In the world of Health Sharing, transparency and clarity are essential for members. ShareWELL operates as a unique alternative to traditional health plans, providing members with a cost-effective way to manage their medical expenses. One of the key components of the ShareWELL system is its Determination Process, which plays a critical role in ensuring that shared funds are allocated fairly and efficiently.
Let’s break down how the determination process works, why it exists, and what members should know to make the most of their membership.
What Is the ShareWELL Determination Process?
Once a member initiates a Sharing Request, the determination process is how ShareWELL evaluates medical expenses for sharing eligibility. Since ShareWELL is not an insurance provider but a Health-Sharing community, the determination process ensures that shared funds are used fairly and responsibly, aligning with the community’s Member Guidelines.
Each member contributes to the community pool, and when someone submits a medical expense, ShareWELL’s determination process reviews the request to decide whether it qualifies for sharing.
How the Determination Fits Into The Sharing Request Process
1. Member Submits a Sharing Request
When a member receives medical care and bills exceed or are expected to exceed their Unshared Amount, they can submit a Sharing Request through ShareWELL’s member portal. This request includes:
- Itemized medical bills and invoices with self-pay discounts applied
- A member’s description of the services received
- Medical records or notes from the visit or related visits
This step ensures the process begins smoothly and all necessary information is available for evaluation.
2. Review of Request
The ShareWELL team carefully examines the submitted request to explore opportunities for:
- Negotiation of medical costs with providers to reduce expenses
- Self-pay resources that could help the member and our community manage costs
- Billing audits to identify duplicate charges, errors, or unnecessary expenses
This step helps ensure that members receive the most cost-effective and accurate pricing before moving forward in the process.
3. Determination Review
The determination team evaluates whether the expense meets ShareWELL’s Member Guidelines for sharing. This review may include:
- A detailed examination of the Sharing Request to ensure it aligns with community-sharing principles
- Input from ShareWELL’s medical director when necessary to confirm medical necessity, pre-existing limitations, and proper classification of the service
- A decision on whether the Sharing Request is eligible, or requires additional documentation
4. Payment and Fund Distribution
Once approved, ShareWELL determines the best way to distribute funds to help members pay for their medical expenses. Available payment methods include:
- Instant debit card for immediate use
- ACH transfer for direct bank deposits
- Online payment portals for seamless transactions with providers
- Member reimbursement when applicable
Together, these steps allow ShareWELL members to receive financial support efficiently.
Why Does ShareWELL Have a Determination Process?
The determination process exists to ensure that ShareWELL operates sustainably and equitably. Here’s why it’s essential:
- Correct Allocation of Resources
- With thousands of members contributing to the community, the determination process ensures that shared funds are used fairly for eligible Sharing Requests.
- Ensure Eligibility
- Holding each member to the same standards for eligibility allows the community to keep the monthly contributions of its members as low as possible.
- Sustainability of the Community Model
- By managing funds responsibly, ShareWELL ensures that future Sharing Requests can be met without financial strain on the community.
- Encouraging Cost-Effective Healthcare Choices
- The process promotes responsible healthcare spending, ensuring members make informed decisions about their medical treatments.
What Members Should Know About the Determination Process
For members to navigate ShareWELL successfully, they should keep the following in mind:
1. Know What’s Eligible
Members should review ShareWELL’s Member Guidelines on eligible expenses. While medical bills related to pre-existing conditions are the most common reason the determination process will find a bill ineligible. Even bills related to pre-existing conditions are eligible for sharing starting in year 2.
2. Submit Complete Documentation
To avoid delays, members should ensure that they submit all necessary documents, including invoices and medical records, when submitting a Sharing Request.
3. Understand Personal Responsibility
Although ShareWELL provides a Health Sharing alternative, it is not traditional insurance. Members are still responsible for:
- Their Unshared Amount (similar to a deductible)
- Out-of-pocket costs for ineligible expenses
- Working directly with providers as self-pay patients
- Tools are available in the member portal whether bills are eligible or not, to help them be smart shoppers of healthcare.
4. Ask Questions When in Doubt
If a Sharing Request is denied or partially shared, members can reach out to ShareWELL’s support team for clarity and assistance. The process is designed to be transparent, and members are encouraged to stay informed.
Final Thoughts
The determination process is a vital part of how ShareWELL functions. By ensuring that shared funds are allocated fairly and responsibly, ShareWELL maintains its community-driven approach to managing healthcare costs.
Understanding the process allows members to:
✅ Submit requests efficiently
✅ Gain transparency in healthcare
✅ Maximize the benefits of being part of a Health Sharing community
For any questions about eligibility, medical need submissions, or the determination process, members should visit ShareWELL’s online portal or contact support.
By working together, ShareWELL members can continue to experience a fair and transparent cost-sharing model that prioritizes accessibility, affordability, and community support. 🚀