Are there any specific medical conditions that have an exclusion or waiting period?

The Guidelines of our medical cost sharing partner state that health conditions that have been diagnosed or that have had exhibited observable symptoms within 36 months prior to the Membership effective date will not be shareable for a period of time. A look-back period of 36 months applies to all prior medical conditions for all those who wish to become Members.

A pre-existing medical condition, as previously defined, is a condition for which the applicant has either received medical treatment, taken medications for, or exhibited observable symptoms (regardless of whether diagnosed or not). However, any prior medical condition that has not exhibited symptoms or been treated during the 36 contiguous months prior to Membership effective date is considered cured and will have no sharing restrictions.

Pre-existing medical conditions will become partially eligible for sharing after the first year on an incremental scale that is tied to Membership tenure (as below). Sharing restrictions do not apply for high blood pressure, as long as the Member has not been hospitalized for high blood pressure in the 36 months prior to Membership and the condition is controlled through medication and/or lifestyle. However, medication* for treatment of high blood pressure as a chronic condition is not shareable.

Medical costs (except some medications*) associated with pre-existing conditions are

  • Not shareable at all during the first twelve months of membership (following the effective date of services).   
  • Shareable up to a maximum of $15,000 cumulative during months 13-24 (following the effective date of services).   
  • Shareable up to a maximum of $30,000 cumulative during months 25-36 (following the effective date of services).   
  • Fully shareable in month 37 and beyond (following the effective date of services).   
  • However, * the cost of maintenance (vs. curative) medications and related maintenance equipment associated with pre-existing conditions are never shareable.
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