What Medical Expenses Are Eligible for Sharing?

One of the most practical things to understand as a Universal HealthShare member is what medical expenses can be shared. This is worth knowing before you need care, not after.

For the specifics that apply to your program, always refer to your Sharing Guidelines in the member portal.

What Is Eligible Before Your NSA Is Met
The Non-Sharable Amount (NSA) is the amount you are responsible for each year before most eligible expenses can be shared. But several services are available right away, without first satisfying your NSA:

• Primary care office visits (consultation fee applies per visit)
• Urgent care office visits (consultation fee applies per visit)
• Specialist office visits (consultation fee applies per visit)
• Telemedicine: Unlimited, available 24/7, with no consultation fee
• Preventive care: After your program’s waiting period, one routine physical or well child exam per year is eligible, up to the annual limit in your Sharing Guidelines•
• UHSRx prescriptions: Included in all programs at no extra cost, with over 1,000 common generic medications available at no charge

These are the services most members use most often, and they are accessible from early in your membership.

What Becomes Eligible After Meeting Your NSA
Once you have satisfied your Annual Non-Sharable Amount, a broader range of eligible expenses can be shared, subject to waiting periods, visit limits, and program guidelines:

• Hospitalization: Inpatient care at any accredited hospital in the continental U.S. Pre-notification required for non-emergency stays.
• Surgery: Inpatient and outpatient surgical procedures that are medically necessary. Elective cosmetic surgery is not eligible, with limited exceptions.
• Specialist care: Both in-network and out-of-network specialist visits are eligible, subject to program rates.
• Diagnostic tests and imaging: Lab work, X-rays, MRIs, and other imaging accessed through a non-hospital, in-network facility.
• Maternity: Eligible for members who have been enrolled for at least 10 months, including prenatal visits and labor and delivery.

Sharing percentages after the NSA vary by program. UHS Standard programs share a percentage of eligible expenses, with an optional Annual Co-Share Maximum that can raise sharing to 100% once met. Thrive HealthShare programs share 100% of eligible expenses after the NSA is satisfied. Review your Sharing Guidelines for the details that apply to your program.

About Consultation Fees
Universal HealthShare programs do not use co-pays. Instead, there are per-visit consultation fees for office visits that are your responsibility and are not shared. These vary by program and service type. Check your Sharing Guidelines for the fees that apply to your specific program.

What Is Generally Not Eligible
A few categories that are generally not eligible include:

• Pre-existing conditions during the initial membership period: UHS programs have waiting periods for conditions that existed before enrollment. The length of the waiting period and the path to full eligibility differ between programs, so check your specific Sharing Guidelines.
• Elective cosmetic surgery: Not eligible, with the exception of reconstructive mammoplasty following breast cancer.
• Comprehensive mental health and substance use treatment: Programs include a limited number of visits per year for psychiatric medication management. Broader mental health therapy is not covered in core programs, though the Health Tools add-on provides access to virtual mental health counseling.
• Dental and vision: Not included in core programs. The Health Tools add-on provides discounts on dental and vision care.

When You Are Not Sure, Ask Before You Go
If you are unsure whether an upcoming service will be eligible, reach out to UHF member support before you receive care. It is much easier to get clarity ahead of time and we want to help you understand every step of the way.

For non-emergency inpatient stays and outpatient surgeries, pre-notification is required. Call us at (888) 636-7119.

→ Ready to review your Sharing Guidelines or submit an eligible expense? Log into your member portal.