BENEFIT PLANS
HEALTHSHARE CONNECTION +
MEGA PLAN
MEDICAL COST-SHARING MEMBERSHIP
HSC + MEGA PLAN
MEGA PLAN
PHCS Network of Doctors
Unlimited Telehealth – No Copay
Behavioral Telehealth
Prescription Discount Card
Doctors & Specialist Office Visits
Dental & Vision
Limited Lab Work
Out-Patient Testing
Urgent Care Visits
HEALTHSHARE
Surgery Care
Emergency Room Procedures
Covid Related Care
In-Patient Hospital Care
Outpatient Procedures
Extended Lab Work
Extended Out-Patient Testing
Accident Care
Maternity (See Limitations)
REQUEST A QUOTE
EXPLANATION OF
PLAN BENEFITS
For so many employers the goal of healthcare is to provide employees with both an ACA compliant plan and a full range of medical benefits. The challenge of today’s employers is to find this combination of services at the lowest possible cost. The HealthShare Connection + Mega Plan is a non-insurance alternative for managing large healthcare costs. This is a membership-based cost-sharing program, whereby members can have their approved medical expenses paid by the community (with a minimal portion paid by the member). This plan combines the HealthShare Connection Plan (extended care related expenses) with all of the benefits of National Health’s Mega Plan (first-dollar coverage for out-patient medical needs) to deliver a well-rounded alternative to traditional health insurance.
Here are some important terms we use when discussing the HSC + Mega Plan.
PLEASE NOTE: Individuals and families can have unlimited needs throughout the year, however, they are only responsible for paying a non-shareable amount ($1500) for the first 3 (individuals) or 5 (families) needs. This non-shareable amount can become less by utilizing the copay program included in their HSC + Mega Plan.
HOW IT WORKS
HSC offers membership to a cost-sharing community of like-minded individuals for the purpose of sharing legitimate healthcare expenses between members. Our members lead a healthy lifestyle and agree to established guidelines put forth by HealthShare Connection that encourage good health (and in turn, fewer medically necessary treatments). Members will not be excluded based on pre-existing conditions, but limitations may apply.
- Individual/Family joins the HealthShare Connection Cost-Sharing Community by electing membership. Member begins to contribute monthly to sharing in the medical Needs of the Community.
- When Member has an eligible medical “Need” caused by an injury or illness, they pay their Non-Shareable Amount (NSA) and the remaining bills are submitted to the Community by using their membership card at time of service.
- Member’s NSA of $1500 can become less if any National Health coverage has been utilized for medical needs.
- Community shares funds with Member for the eligible Need
PRE-EXISTING CONDITIONS
Any pre-existing medical condition whether diagnosed or not, that has been active or needed treatment within 36 months prior to a Member’s membership start date is subject to sharing limitations. Pre-existing conditions will become eligible for sharing based on the Member’s tenure in the HealthShare Connection + Mega’s cost-sharing community as indicated by the following graduated sharing schedule:
| TIME CONSTRAINTS FOR PRE-EXISTING CONDITIONS AFTER MEMBERSHIP EFFECTIVE DATE | SHARING ELIGIBILITY |
|---|---|
| First 12 Months | Not Shareable |
| Months 13-24 | Shareable to $15,000 |
| Months 25-36 | Shareable to $30,000 |
| Months 37 & After | Shareable |
MEMBER HAS A LARGE
MEDICAL EXPENSE RELATED TO A NEW INJURY OR ILLNESS
EXAMPLES
Broken Bones, Lacerations, Fractures, Cyst Removal, Infectious Diseases, Stroke, Heart Attacks, Cancer, Liver Disease, Gastrointestinal Issues, Medically Necessary Surgery… etc.
HSC COST-SHARING PROCESS
HEALTH & WELLNESS VISITS
Included in this MEC coverage are 15 Covered Preventative Services for Adults, 23 additional Covered Preventative Services for Women (including pregnant women), and an additional 26 Covered Preventative Services for Children and Newborns. The majority of the covered preventative services included in this plan allow for screenings, vaccinations, counseling and other preventative tests. It also includes a colonoscopy screening for adults 50 years and older every 5 years as well as an annual mammogram screening for women 40 and over.
MEDICAL & BEHAVIORAL TELEHEALTH
Lyric is a virtual-first healthcare platform built to streamline access, reduce friction, and drive meaningful claims cost reduction by guiding members to the right care, when and how they need it. By combining an integrated suite of virtual care services with 24/7 care navigation, Lyric delivers a seamless, connected healthcare experience from first touch to resolution. Our focus is on fostering the well-being of our members by providing healthcare services that prioritize individuals’ health, ensuring their safety, and advocating for overall wellness.
Emergency Room Plan Policy
We are committed to supporting members in true emergencies
while also protecting the sustainability of our community.
Emergency rooms are the most expensive place to receive care, and inappropriate use can dramatically increase costs for everyone. In fact, many ER visits involve conditions that could have been safely treated elsewhere, often with shorter wait times and a much lower financial impact.
Emergency room services are eligible for sharing only when a true medical emergency exists, defined as:
A condition that a prudent person believes could result in:
- Serious jeopardy to health
- Serious impairment of bodily functions
- Serious dysfunction of any organ or body part
Examples include:
- Chest pain / suspected heart attack
- Stroke symptoms
- Severe bleeding
- Difficulty breathing
- Major trauma
TOBACCO & VAPING
SHARING RESTRICTIONS
Due to the increased likelihood of higher medical costs associated with tobacco and vaping use, HSC households with one or more tobacco or vape users are required to contribute an additional $75 per month. Unless tobacco or vape users age 50 and older are confirmed tobacco-free for 12 months, they will have a sharing limit of $25,000 for each of the following conditions: 1. Cancer, 2. Heart Conditions, 3. COPD, 4. Stroke.
EMPLOYER
CONTRIBUTIONS
This plan requires an employer contribution of $30 per employee to maintain the “employer-sponsored” designation requirement of the ERISA Act legislation that this plan is founded on. Employers may contribute more than $30 per employee if they so choose, but the minimum standard contribution starts at $30 per employee.
INCLUSIONS
Our HealthShare + Mega Plan includes all claims fees, administration costs, a Total Telehealth package through MeMd with no copay on medical services, and a Prescription Discount Card. This plan includes all government reporting including Forms 1094’s, 1095’s, 720 Report, Form 5500 section 4980H, PCORI annual filing fee, Cobra Notices, and TPA fees. It also includes the
COPAY PROGRAM SHOWN HERE.
COVERED PREVENTATIVE SERVICES
COVERED PREVENTATIVE SERVICES
ALL ADULTS
- Blood Pressure Screening
- Cholesterol Screening
- Type II Diabetes Screening
- Diet counseling
- Syphilis Screening
- HIV Screening
- Sexually Transmitted Infection Prevention Counseling
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Alcohol misuse screening and counseling
- Aspirin use for men ages 45-79 & women ages 55-79 to prevent CVD when prescribed by a physician
- Tuberculosis screening
- Depression screening
- Colorectal cancer screening for adults 45-75 years
- Lung cancer screening for adults 50- 80 years at high risk for lung cancer
- Colonoscopy (Colorectal cancer screening for adults starting at age 50, limited to one every 5 years)
- Immunizations and vaccines (Hepatitis A&B, Herpes, Zoster, Influenza, Measles, Mumps, Tetanus, Rubella, Human Papillomavirus, Meningococcal, Pneumococcal, Diphtheria, Pertussis)
- Abdominal aortic aneurysm one-time screening for age 65-75
- Depression screening & counseling
- Obesity screening
- Fall prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over
- Statin preventive medication for adults 40-75 years at high risk
- Aspirin use for adults ages 50-59 to prevent CVD and colorectal cancer
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV negative adults at high risk
- Hepatitis B screening for people at high risk
- Hepatitis C screening adults 18-19 years
COVERED PREVENTATIVE SERVICES
WOMEN’S SERVICES
- Birth control (see prenatal/postnatal below)
- Bone density screening for women over 65 years or women 64 years and younger who have gone through menopause
- Breast cancer genetic test counseling (BRCA)
- Breast cancer screening mammogram every 1-2 years for women 40 years and older
- Breast cancer chemoprevention counseling
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits
- Cervical cancer screening (Pap smear)
- Chlamydia infection screening
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant
- Domestic and interpersonal violence screening and counseling for women
- Gonorrhea screening
- HIV screening and counseling
- PrEP (pre-exposure prophylaxis HIV prevention medication for HIV-negative women at high risk
- Sexually transmitted infections counseling
COVERED PREVENTATIVE SERVICES
PRENATAL / POSTNATAL SERVICES
- Breastfeeding support and counseling from trained
- providers, and access to breastfeeding supplies for pregnant and nursing women
- Birth control including: diaphragms, sponges, birth control pills and vaginal rings, intrauterine devices (IUDs, Plan B® and ella®, sterilization procedures, patient education and counseling
- Folic acid supplements
- Gestational diabetes screening for women 24 weeks pregnant or later or higher risk
- Gonorrhea or Syphilis screening for women at higher risk
- Maternal depression screening for mothers at well-baby visits
- Pre-eclampsia prevention and screening
- Rh-incompatibility screening including follow-up testing
- Expanded counseling for pregnant tobacco users
- Urinary tract or other infection screening
COVERED PREVENTATIVE SERVICES
NEWBORN SERVICES
- Bilirubin concentration screening
- Blood screening for newborns
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes
- Hearing screening
- Hemoglobinopathies or sickle cell screening
- Hypothyroidism screening
- Immunizations: (Varicella, Hepatitis A&B, Flu Shot, Inactivated Poliovirus. Measles, Mumps, Tetanus, Rubella, HPV, Meningococcal, Pneumococcal,
Diphtheria, Pertussis, Rotavirus, Haemophilus flu type b) - Phenylketonuria (PKU) screening
COVERED PREVENTATIVE SERVICES
ALL CHILDREN SERVICES
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Blood pressure screening for children
- Depression screening beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Sexually transmitted infection prevention counseling and screening for adolescents
- Tuberculin testing
- Vision screening
- Well baby and well-child visits
- Fluoride supplements
- Hearing screening for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly
- Hematocrit or hemoglobin screening for all children
- Hepatitis B screening for adolescents at higher risk
- HIV Screening for adolescents at higher risk
- Lead screening for children at risk of exposure
- Obesity screening and counseling
- Oral health risk assessment, 6 months to 6 years
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk