Phoenix sharing rules

What counts as one medical need

A medical need is an eligible illness, injury, condition, pregnancy or treatment that results in medical expenses. Everything tied to the same underlying issue is generally one medical need, even when care runs over months and involves several providers and facilities. Seeing three different specialists about the same problem does not create three needs, and neither does crossing into a new month or a new calendar year.

That matters for long-running conditions. Once you have satisfied the IUA for an active need, you do not pay another one just because treatment continues. One cancer diagnosis covering surgery, chemotherapy, radiation, imaging, oncology visits and hospital stays can stay a single medical need for years.

A need can become a new need after at least twelve consecutive months with no symptoms, no active treatment, no condition-related medication and no related care. Routine surveillance on its own does not necessarily restart that clock.

The IUA, and changing it

Your Initial Unshareable Amount is what you pay toward a single eligible medical need before sharing begins. Expenses used to satisfy it have to be based on reasonable cash-pay or negotiated rates. An inflated billed charge does not count toward it.

You can change your IUA whenever you like. The revised amount does not apply to a sharing request already open, or to a new medical need that begins within 60 days of the change. Needs that start in that window stay on the old IUA.

The three-IUA safeguard and the $500 threshold

You are responsible for no more than three IUAs in any rolling twelve months, measured from the date each IUA was satisfied. An IUA has to be satisfied within eight months of the related date of service to count toward the three.

Once three are satisfied, no further IUA applies until an earlier one falls out of the twelve-month window. In its place, each new eligible need has to exceed $500 in eligible expenses to qualify. If it does, eligible expenses can be shared from the first dollar. If it does not, the whole amount is yours.

Care Coordination, and the hospital fee

Care Coordination is generally optional, but using it is worth real money:

A $500 Non-Navigated Hospital Fee may apply when you get non-emergency hospital-based care without contacting Care Coordination first, where contacting them was reasonably possible. It is separate from the IUA and can apply even after you have satisfied three IUAs. Phoenix may waive it when advance coordination was impractical or when good discounts were obtained anyway. It never applies to qualifying emergency care.

Emergency care

Go. Get treated. You are not required to contact anyone first. Emergency status is judged on the symptoms and circumstances you reasonably knew at the time, not on whatever the diagnosis turns out to be, so you are not punished for a sensible call that turns out to be nothing. Contact Phoenix once things are stable so the rest of the care can be coordinated.

Maternity and newborns

Maternity expenses can be eligible when the expected delivery date is at least twelve months after your membership start date. A pregnancy due inside that first year is not eligible for maternity sharing. An otherwise eligible pregnancy does not lose eligibility just because a medically necessary early delivery lands before the twelve-month mark.

An eligible pregnancy is generally one medical need covering prenatal care, delivery and postpartum. It has its own IUA:

The maternity IUA counts toward your three-IUA rolling maximum. It may be reduced when you work with Care Coordination, and the Care Navigation Discount can also apply without that when the birth is attended by a licensed midwife and the total negotiated or cash cost of maternity and delivery is $7,500 or less.

Add the baby within 30 days of birth. Routine newborn care tied to an eligible maternity need can be included, which can cover one in-hospital paediatrician visit, routine immunizations, routine lab testing and routine hearing screening. Anything beyond routine newborn care may be treated as a separate medical need under the newborn’s own provisions.

Medically necessary treatment of a miscarriage may be eligible, subject to the same maternity eligibility requirements.

Conditions you had before joining

Phoenix calls these Pre-Membership Conditions. A condition counts if it existed in the 24 months immediately before your start date and any of the following happened: a diagnosis was made, medical advice was sought or given, treatment was recommended or received, medication was prescribed or taken, diagnostic testing or evaluation happened, medical monitoring happened, or there were signs or symptoms that would make a reasonable person seek medical attention.

You do not need to have had a formal diagnosis for it to count. Equally, an isolated, minor, temporary or medically unrelated symptom does not automatically turn a later condition into a Pre-Membership Condition. There has to be a reasonable medical relationship between the two, and Phoenix may review medical records to work that out.

The $50,000 in months 13 to 24 is a combined per-member maximum, not $50,000 per condition. Phoenix’s own example: $30,000 shared for one condition and $20,000 for another in that window means you have reached the maximum for the period.

Managed chronic conditions are carved out. High cholesterol, diabetes and high blood pressure are not treated as Pre-Membership Conditions when they are effectively managed through medication, diet or other routine care, and you have not been hospitalized for the condition in the twelve months before your start date.

What is not shared

Under the base membership, these are generally not eligible:

• Routine preventive and wellness care, including annual physicals and routine screening
• Mental and behavioral health, including counseling, psychotherapy and psychiatric care
• Substance-use treatment, inpatient or outpatient
• Retail and outpatient prescription medication
• Speech therapy
• Vision care and hearing aids
• Sleep apnea
• Neurodivergent disorders
• Chronic and medically stable conditions
• Cosmetic procedures
• Abortion services
• Professional and paid sports
• Therapeutic treatments
• Fees, interest and taxes

Expenses are also generally ineligible when they are not medically necessary, experimental or investigational, incurred before membership started, related to a Pre-Membership Condition during a period when sharing is unavailable, submitted after the deadline, fraudulent or materially misrepresented, or unsupported by the documentation Phoenix asks for.

Phoenix notes that optional Preventive Sharing and optional prescription sharing may be available under separate guidelines. We do not hold those documents, so treat them as unconfirmed and ask us rather than assuming.

What is shared

Subject to the guidelines, eligible medical expenses generally include:

• Primary physician services related to an illness or injury
• Specialist services
• Diagnostic laboratory services and imaging
• Emergency care
• Hospital services
• Surgery and anesthesia
• Medically necessary outpatient procedures
• Eligible maternity care
• Physical therapy or rehabilitation tied to an eligible medical need
• Eligible transplant services arranged through Care Coordination

Emergency medical needs that happen while you are traveling outside the United States are generally shareable. Travel, lodging and meals are not.

Transplants

Organ and tissue transplants require Care Coordination. A transplant and its related expenses are eligible only when Phoenix coordinates or approves the care in advance, unless an emergency makes that impossible. Going ahead with a non-emergency transplant without them can make the whole thing ineligible, which is about as expensive as a paperwork mistake gets.

Getting your bills in: the eight-month window

Phoenix has to receive the bill, receipt or other required documentation no later than eight months after the date of service. Their own example: care on 15 January has to be submitted by 15 September. This is a different clock from the twelve-month symptom-free period that decides whether an old condition counts as a new need, so do not mix the two up.

If an eligible service happens while your membership is active but the bill lands after it ends, it can still be considered, as long as the need was eligible, membership was active on the date of service, the IUA timing was met and the paperwork arrived on time. Care received after membership ends is not eligible.

If you disagree with a decision

You can ask for reconsideration. Send Phoenix the additional medical records, physician information, billing detail or context, and they will review it and give you a reconsidered determination. If you still disagree, you can ask for a final internal review.

Where someone else is legally responsible for a medical expense, such as car insurance, workers’ compensation, liability insurance, another health plan, Medicare or a responsible third party, that source is generally pursued first. Phoenix does not duplicate what another responsible source has already paid.

Phoenix HealthShare is not health insurance. Membership does not create an insurance contract or guarantee payment of any medical expense. Members remain ultimately responsible for their own medical expenses. Sharing is voluntary and governed by the Phoenix Member Guidelines. Questions about eligibility, sharing, Care Coordination or a bill go to Planstin on 435.571.0011 or Individual@Planstin.com.