At ShareWELL, we are committed to fairness and responsible financial stewardship in our Health Share community. To ensure that members’ contributions are used appropriately, we require medical records in certain situations to determine whether a medical condition qualifies for sharing. By reviewing medical history when necessary, we can uphold our guidelines, protect community resources, and provide clarity on shareability.
Understanding ShareWELL’s Pre-Existing Condition Definition
Although other aspects of the Member Guidelines may affect shareability, the pre-existing condition provision is the most common reason for any limitation on sharing.
A pre-existing condition, as defined by ShareWELL, includes any illness or injury for which a person has:
- Been examined
- Taken medication
- Had symptoms
- Received medical treatment
within 24 months before their membership start date.
For cancer-related conditions, a pre-existing limitation applies if a member has had any testing, preventive treatments, prophylactics, or medications related to a previously diagnosed cancer within 36 months before membership began.
However, high blood pressure, high cholesterol, hyperthyroidism, hypothyroidism, and type 2 diabetes are not considered pre-existing conditions unless the member has been hospitalized for the condition within 12 months before enrollment.
Understanding these guidelines is crucial, as they help determine when medical records are required to evaluate eligibility for sharing.
Year 1: Establishing Eligibility for Non-Acute Conditions
During a member’s first year with ShareWELL, we require medical records for Sharing Requests that have not been sustained from an acute medical event. Medical records allow us to assess whether symptoms, treatment, or medications were present within 24 months of the membership start date for non-acute conditions. This process ensures fairness in sharing while helping us keep a lower monthly contribution for the entire community.
Year 2: Evaluating Cases (Over $30,000)
Starting in year two, ShareWELL narrows the scope of medical record reviews. Instead of requiring records for all non-acute conditions, we usually only request them if we anticipate medical costs exceeding $30,000. For example, if a member requires major surgery or prolonged hospitalization, medical records help confirm that the condition qualifies for sharing.
Year 3 and Beyond: Adjusting for Increased Cost Thresholds
As membership tenure increases, ShareWELL adjusts the threshold for requiring medical records.
- In year three, records are only required when anticipated medical costs exceed $60,000.
- In subsequent years, this threshold continues to increase.
How Members Can Expedite the Process
While ShareWELL assists in gathering necessary medical records, providers often respond more quickly when working directly with a member. As part of the Determination Process, those who actively request and submit their records significantly reduce processing time and move their Sharing Request forward faster.
If needed, ShareWELL is happy to assist in the records request process. In these cases, members will need to sign a HIPAA authorization form, allowing ShareWELL to request and receive medical records on their behalf.
Members and ShareWELL can streamline the process by working together to ensure it is as efficient as possible.
Why This Process Matters
By following a structured and well-defined approach, ShareWELL ensures that all members benefit from shared resources while maintaining fairness, transparency, and financial stability. Members actively participating in the records collection process can help make this process smoother, ensuring faster access to the support they need.