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Big Stuff Health Share, doing business as MyOwn Medical Fund is not an insurance company. Neither this publication NOR membership in Big Stuff Health Share are issued or offered by an insurance company. The purpose of this Member Guide is to help Members understand and identify medical needs that qualify for potential reimbursement and the process by which reimbursements are made. This Member Guide is not for the purpose of describing to prospective Members what amounts will be reimbursed by Big Stuff Health Share.
Membership in Big Stuff Health Share does NOT guarantee or promise that a Member’s Eligible Needs will be shared. Rather, membership in the Big Stuff Health Share community merely guarantees the opportunity for Members to care for one another in a time of need and present their medical needs to other Members as outlined in this Member Guide. The financial assistance Members receive will come from other members’ monthly contributions that are placed in a benevolent fund, and not from Big Stuff Health Share.
THIS PUBLICATION AND MEMBERSHIP IN BIG STUFF HEALTH SHARE SHOULD NEVER BE CONSIDERED A HEALTH INSURANCE POLICY. IF THE MEMBERSHIP IS UNABLE TO SHARE IN ALL OR PART OF A MEMBER’S ELIGIBLE MEDICAL NEEDS, EACH MEMBER WILL REMAIN SOLELY FINANCIALLY LIABLE FOR ANY AND ALL UNPAID MEDICAL NEEDS.
THIS MEMBER GUIDE DOES NOT CREATE A LEGALLY ENFORCEABLE CONTRACT BETWEEN BIG STUFF HEALTH SHARE AND ANY OF ITS MEMBERS. NEITHER THESE GUIDELINES, NOR ANY OTHER ARRANGEMENT BETWEEN MEMBERS AND BIG STUFF HEALTH SHARE, CREATE ANY RIGHTS FOR ANY MEMBER AS A RECIPROCAL BENEFICIARY, A THIRD-PARTY BENEFICIARY, OR OTHERWISE. AN EXCEPTION TO A SPECIFIC PROVISION OF THESE GUIDELINES ONLY MODIFIES THAT PARTICULAR PROVISION AND DOES NOT SUPERSEDE OR VOID ANY OTHER PROVISIONS. THE DECISION BY BIG STUFF HEALTH SHARE TO REIMBURSE A MEMBER’S ELIGIBLE NEEDS DOES NOT AND SHALL NOT CONSTITUTE A WAIVER OF THIS PROVISION OR ESTABLISH BY ESTOPPEL OR ANY OTHER MEANS ANY OBLIGATION ON THE PART OF BIG STUFF HEALTH SHARE TO REIMBURSE A MEMBER’S ELIGIBLE NEEDS.
MEMBERS ARE PRIMARILY RESPONSIBLE FOR ENSURING THAT ALL OF SUCH MEMBER’S MEDICAL EXPENSES ARE TIMELY PAID, REGARDLESS OF THE STATUS OF ANY NEEDS REQUEST.
Participating in Medicare/Medicaid if Medicare/Medicaid eligible.
Filling out the Big Stuff Enrollment Form completely, accurately, and honestly;
Meeting Big Stuff Health Share’s qualifications based upon lifestyle choices and medical history;
Agreeing to abide by the Foundations of Membership; and
Paying a full, monthly contribution amount* in accordance with the Member’s Participation and IUA Elections, with the first contribution being due on or before the Effective Date and all subsequent contributions being due on the first day of each calendar month.
Membership applications will be accepted on a case-by-case basis.
A. Employee Only
B. Employee + 1 dependent
C. Employee + 2 or more dependents
IUA (Whatcha Gotta Pay First) Elections:
Dependents may be included in Primary Member’s membership if:
Spouse or Child is a legal dependent of Primary Member (marriage, biological birth**, adopted, legal guardianship, stepchildren, etc.)
Immediate family members included up to 8 total family members. A $10.00 monthly fee for each additional member is assessed thereafter.
Child dependent is unmarried***, and
Child dependent is under the age of 26****
Membership will begin on the 1st day of the upcoming month if:
Member enrolls by the 25th of the current month, and
Big Stuff Health Share receives the Member’s monthly contribution amount by the 1st of the effective month.
*Payment must be received no later than the final day of the participating month for membership to remain in Active status.
**To include a newborn child in a Primary Member’s membership retroactive to the birth date, Big Stuff Health Share must receive notification of the addition to the household within thirty (30) days of birth. If notification is received more than thirty (30) days after the child’s birth, then the child’s effective date will be the 1st day of the month following the month in which notice is given.
***Dependents who are married may enroll in a membership separate from that of the parents.
****Dependents age 26 and older will be automatically removed from Primary member’s membership and must enroll under a separate plan to share medical expenses.
To share in a member’s medical expenses, Big Stuff Health Share will first determine the eligibility and shareability of a medical need.
When a need is determined Eligible and Shareable, Big Stuff Health Share will disburse the Shareable Amount to the appropriate source (via reimbursement to the Member for actual amounts paid by the Member or via direct payment to the Member’s medical provider.)
Eligible Medical Needs
An Eligible Medical Need is defined as follows:
The occurrence of an injury or illness on a per Member, per incidence basis;
Resulting in medical treatment expenses which are:
for treatment performed by a licensed medical professional;
for treatment that has been pre-approved by the medical provider; and
for treatment related to the same injury or illness;
Which injury or illness Is not deemed a Pre-Existing Condition; and
Which injury or illness was not caused by the Member’s illegal activities or activities in violation of the Foundations of Membership.
Shareability (what healthcare expenses will be shared)
An Eligible Medical Need is considered Shareable (payable) if:
The date of service is within a period of Active status;
All required documentation listed in this section (an itemized bill, IUA receipt, etc.) is submitted within 6 months of the service date;
Itemized bills listing CPT codes for the services provided, the name, address, and contact information for the medical provider and the patient name; and
Receipts showing proof of Member’s payment of all medical expenses charged and any discounts provided by the medical provider.
If a bill is adjusted, or if a Member makes a payment or obtains a discount or any refund or reimbursement after submission of a Needs Request, the Member shall promptly amend or supplement the applicable Needs Request to ensure the accuracy and completeness of each Needs Request;
The IUA has been paid in full within a period of Active status; and
The need is reported prior to, during or within 2 hours of the time of service to a licensed medical professional associated with Big Stuff through a 24-hour medical line (435-850-7396)
An IUA is required for each separate Eligible Medical Need experienced within a household for up to 3 Eligible Medical Needs within a 12-month period. Additional Eligible Medical Needs arising within that 12-month period exceeding a $500 threshold will be fully shareable after the first $500 related to such Eligible Medical Need is paid by Member.
Maximum Shareable Amount
Once a medical need is deemed an Eligible Medical Need and the IUA is paid, the community will share 100% of the remaining medical expenses for that Eligible Medical Need subject to the Member’s Lifetime Limit until the Member is symptom and treatment-free for 12 months.
Insurance and Government Programs
If a Member is eligible for benefits through insurance arrangements, government programs, etc., those entities will always be considered the primary payer, and Big Stuff Health Share will always be the payer of last resort. If primary insurance pays greater than 50% of the allowable charges, the IUA will be waived.
Late Fees and/or Interest
Late payment fees and Interest will not be shareable if they are a result of a Member’s delay in paying the IUA amount or submitting required documentation.
A pre-existing condition is any illness or injury within 24 months prior to the Effective Date for which a Member:
Has been diagnosed;
Received medical treatment;
Has been examined; or
Has taken medication
An otherwise Eligible Medical Need resulting from a pre-existing condition will only be Shareable during the first 12 months after the Effective Date if the condition is:
Fully cured and
Symptom- and treatment-free for 24 months before the Effective Date
Pre-Existing Condition Waiting Period
Pre-Existing Conditions have a waiting or phase-in period based on years of continued Membership:
1st Year – Waiting Period for all Pre-Existing Conditions. No otherwise Eligible Medical Needs considered Pre-Existing Conditions will be shared or paid during the first 12 months after the Effective Date
2nd Year – Up to $25,000 of Eligible Medical Needs considered Pre-Existing Conditions may be Shareable
3rd year – Up to $50,000 of Eligible Medical Needs considered Pre-Existing Conditions may be Shareable
4th year and beyond – Up to $100,000 per year of Eligible Medical Needs considered Pre-Existing Conditions may be Shareable
This program exists to help protect existing Members’ contributions from immediate, extensive medical out-payments for conditions existing prior to the membership for newly added Members.
Maternity Needs may only be Sharable if conception occurs 90 days or longer after the applicable Member’s Effective Date. Eligible Medical Needs related to prenatal, birth and postnatal needs may be Shareable up to $16,000.00 for normal vaginal delivery and $20,000.00 for cesarean delivery. The member will be required to pay only one IUA for the sharable need.
Early Sharing Request
Maternity Needs may be Shareable prior to the child’s birth only if the maternity care provider will apply a discount or reduce UCR Costs when paid in advance.
Maternity Needs related to in-home births may be Shareable if the expenses related thereto are less than what would normally be shared by the community, Big Stuff may waive the IUA requirement. Prior written approval must be obtained from Big Stuff to waive the IUA.
Maternity Needs for children born prior to the start of the 37th week of pregnancy may be Shareable.
Eligible Medical Needs related to the abortion of a living, the unborn child may not be Shareable, except in cases where extenuating circumstances exist and the mother’s life is at risk if the abortion is not performed.
Alcohol or Drug Abuse Treatment
Eligible Medical Needs related to alcohol or substance abuse or chemical dependency may be Shareable up to a $3,000 maximum Shareable amount per Member for the lifetime of such Member, provided that such Eligible Medical Need was not caused by Member’s violation of the Foundations of Membership after the Effective Date.
Eligible Medical Needs rising from non-seasonal allergies may be Shareable.
Alternative Medical Treatment
Eligible Medical Needs for alternative medical treatments are, generally, considered Shareable. To be Shareable, the treatment should be considered safe and effective. The Member must receive written approval from Big Stuff Health Share before receiving such treatments.
To receive approval from Big Stuff Health Share, the requesting Member should provide:
The provider’s notes on current condition;
Explanation for why the alternative treatment was chosen;
Explanation for why the alternative medical treatment should be shared;
An estimated list of costs; and
Written approval from a licensed medical provider (MD, DO, PA-C, APRN, NP) affiliated with Big Stuff Health Share.
Eligible Medical Needs for ambulatory transport when medically necessary due to severity, proximity, and circumstances associated with a specific illness or injury may be Shareable.
Eligible Medical Needs related to the correction of hearing loss may be Shareable. Hearing aids are not Shareable but may be provided through the Osmond Foundation or other charitable organizations at the discretion of a licensed medical provider affiliated with Big Stuff Health Share.
Eligible Medical Needs resulting from an automobile accident may only be Shareable when a third party or insurance entity cannot be held liable. Auto, casualty, property, and other insurance will always take first priority positions prior to consideration of Big Stuff.
Eligible Medical Needs for chiropractic treatment of a musculoskeletal injury or disease may be Shareable for up to 25 office visits and includes related items for treatment for up to 120 days. All other chiropractic services will be treated as an Alternative Medical Treatment.
Chronic Conditions, that are not considered pre-existing, will be eligible for sharing up to 12 months. A new IUA will be required if member is symptom free for greater than 12 months.
Only expenses pertaining to the repair of a disfiguration resulting from an eligible medical need are shareable.
Dental & Vision
Dental & Vision Services are deemed a non-shareable expense. Only expenses for dental work or vision repair resulting from an Eligible Medical Need (accident or injury) may be Shareable.
Expenses for fertility treatments are excluded from sharing.
Health Sharing Eligibility
Eligible Medical Needs related to any shared need will be considered only if the member is currently participating in Big Stuff Health Share at the time of their request.
Eligible Medical Needs related to hospice care may only be Shareable for 90-day periods with physician approval or certification of a terminal illness.
Eligible Medical Needs resulting from hospitalization may be Shareable only at a semi-private room rate and only if a licensed medical provider prescribes ICU or quarantine.
Expenses for hyperbaric therapy may only be Shareable when recommended by a licensed medical provider for treatment of an Eligible Medical Need.
Injuries Obtained from Certain Acts
Injuries or illnesses resulting from participation in a riot, criminal act, assisted suicide, or euthanasia are excluded from sharing.
Laboratory Tests and Checkups
Expenses for laboratory tests may only be Shareable when related to the need and prescribed by a licensed medical provider due to symptoms of an Eligible Medical Need.
Long Term Care and Skilled Nursing
Expenses for long term care and skilled nursing when prescribed by a licensed medical provider as a result of an Eligible Medical Need may be Shareable.
Expenses for massage therapy may only be Shareable if prescribed by a licensed medical provider for the treatment of an Eligible Medical Need, and for only up to 10 sessions.
Expenses for medical equipment may be Shareable, subject to the limitation set forth below, only if:
Prescribed by a licensed medical provider associated with Big Stuff Health Share
It is reasonably necessary for the treatment of an Eligible Medical Need
It is approved by Big Stuff Health Share.
Limitation: Big Stuff Health Share will share the lesser of: (i) the purchase price for the medical equipment; and (ii) the rental costs of such medical equipment during the treatment period.
Expenses for medical supplies used in the treatment of an Eligible Medical Need may be Shareable within 180 days of the start date of a treatment prescribed by a licensed medical provider.
Expenses for mental health treatment may only be Shareable when approved in advance by Big Stuff Health Share up to a maximum lifetime limit of $1,500 per Member.
Expenses for naturopathic medicine may only be Shareable with prior written approval from Big Stuff Health Share.
Expenses for the following newborn treatments are shareable:
Eligible Medical Needs for nutritionists may only be Shareable when prescribed by a licensed medical provider and with documentation from a licensed medical provider affiliated with Big Stuff Health Share.
Eligible Medical Needs related to organ transplants may only be Shareable when the underlying condition is not deemed a pre-existing condition and approved by a licensed medical provider affiliated with Big Stuff Health Share.
Eligible Medical Needs for physical therapy for inpatient treatment and up to 20 outpatient treatments may be Shareable.
Only medications required to treat an Eligible Medical Need may be Shareable for a period of up to 3 months. All other medications are not Shareable.
Colo-rectal screening will be shared up to $750.00. Screening colonoscopy will be covered with a flat rate of $1650.00. Breast Cancer Screening, i.e. mammogram, screening ultrasound, will be covered at a flat rate of $300.00. Big Stuff will waive the IUA for these procedures. Recommendations for locations for these screenings can be made by Big Stuff member advocates. All screenings will be ordered by the provider and will follow the American Cancer Society Guidelines for need and frequency of testing.
Expenses related to office visits may be Shareable when part of an Eligible Medical Need.
Expenses for speech therapy may only be Shareable when resulting from an Eligible Medical Need up to 25 outpatient visits per Eligible Medical Need.
Spine & Neck Surgery
Due to the complexity and unpredictability of outcomes, any services related to pre-existing back or neck pain will be considered with a maximum shared amount of $15,000.00.
Eligible Medical Needs resulting from injuries sustained in sporting activities, other than those specifically excluded herein, may be Shareable. Eligible Medical Needs related to high-risk sporting events such as boxing, base jumping, bungee jumping, or paid-to-win combat sports are not Shareable unless otherwise determined by Big Stuff Health Share. Medical needs related to collegiate or professional sports are not Sharable.
Expenses for elective sterilization procedures such as tubal ligation and vasectomy are excluded from sharing.
Expenses related to Surrogacy, regardless of whether the surrogate is a Member, are excluded from sharing.
Eligible Medical Needs for surgical weight reduction may be Shareable, subject to a lifetime limit of $3,000 per Member when prescribed by a licensed medical provider and approved by Big Stuff Health Share.
Big Stuff Health Share
Foundations for Membership
Each Member of Big Stuff Health Share must comply with the following requirements in order to preserve its membership in Big Stuff Health Share and be eligible to participate in the health share.
The requirements below benefit all Members by assuring honor and integrity on the part of Members and by minimizing medical risks and ensuring proper accountability while encouraging good health practices.
All Big Stuff Health Share Members must agree with and attest to the following statements:
I believe that a community of moral, ethical, and health-conscious people can most efficiently and effectively encourage and care for one another by directly sharing the costs and expenses associated with each other’s health care needs.
I understand that Big Stuff Health Share is a benevolence organization, not an insurance entity and that while Big Stuff Health Share assures that every effort will be made to have Members fulfill their monthly sharing commitment, Big Stuff Health Share, in and of itself, cannot guarantee payment of any medical expenses.
I agree to practice good health measures and strive for a balanced lifestyle.
I agree to contact Big Stuff Health Share by either calling the hotline (435-446-9696) or by emailing email@example.com prior to seeking or obtaining any medical treatments (except in the case of an emergency where I will seek immediate medical attention) to ensure that I am receiving the appropriate medical treatments at a fair price and to verify the Shareability of such medical treatment.
I agree to refrain from the usage of any form of illicit/illegal drugs and excessive alcohol
consumption, all of which are harmful to the body. I understand that if members in the
household use any form of tobacco, I will contribute an additional $50.00 (fifty) dollars per month.
I believe I am obligated to care for my family and that physical, mental, or emotional abuse of any kind to a family member or anyone else is morally wrong.
I agree to submit to mediation followed by subsequent binding arbitration, if needed, for any instance of a dispute with Big Stuff Health Share or its affiliates.