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FAQ / Glossary
Keep reading to find answers to questions about your plan, enrolling, how it works, or to learn some important definitions.
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Faqs
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Enrollment
To enroll in a ClearShare membership, only the primary member must have a Social Security Number. Dependents are not required to have a Social Security Number.
To enroll in a Major Medical plan, all members must have a Social Security Number.
No, you do not need a medical checkup to enroll, but you will be asked specific questions about your medical history on the enrollment form to ensure the membership or plan you are enrolling in will be a good fit for you.
Yes, you can enroll in dental and vision plans without bundling them with medical.
To cancel your plan, contact planhelp@clearwatersavings.com. A 30 day notice is required to cancel your plan. The plan will be terminated as of the 1st of the month following the 30 day notice.
If I have a HSA plan already, do I need to set up a new account or can I use the one I already have?
HSA plans from Clearwater com with a free Clearwater HSA! You can enroll in your Clearwater HSA when you enroll in the plan. With Clearwater’s HSA, you get:
- One card for all your healthcare-related needs
- Integration with Clearwater’s member portal
- Physical & virtual HSA debit cards
- Simplified claims process with online tools
- A platform that supports English and Spanish languages
- Integrated investment tools for accounts over the minimum threshold
Learn more:
If you already have an HSA plan and don’t want to switch, you can opt-out of the Clearwater HSA at enrollment.About Clearwater
Clearwater Benefits is a healthcare vendor. Clearwater offers a wide variety of high quality, highly affordable healthcare solutions tailored to meet individuals’ unique needs via traditional insurance plans, healthshare-based solutions, and supplemental insurance offerings.
Clearwater offers ClearShare memberships and Major Medical plans.
ClearShare is a great fit for individuals and families who are looking to lower their monthly costs and out-of-pocket expenses as much as possible. Because ClearShare is not insurance, some administrative work will fall on members and some limitations apply, as outlined in the Member Guidelines. These guidelines keep costs low for the whole community.
Advanced ClearShare Membership: Enjoy low out-of-pocket costs for common services like doctor visits, prescriptions, and tests. Perfect for families looking to make the most out of their healthcare.
Basic ClearShare Membership: Low costs for doctor visits and prescriptions, plus no visit limits or maximum payouts.
HSA + ClearShare membership: Pairs an HSA Minimum Essential Coverage (MEC) plan with a ClearShare membership. This plan is for those interested in having and contributing to a Health Savings Account.
ClearShare memberships: A healthshare-only plan that helps provide members a safeguard against unexpected medical expenses including accidents or illnesses. It does not provide any day-to-day coverage such as preventive or primary care doctor visits, diagnostics, and drugs.
Major Medical are all-insurance plans, offering lower costs and better benefits than most plans found in the Marketplace. Agents can enjoy a range of deductible options, low copays, lower max out-of-pocket, and affordable premiums. These plans have no limitations, such as pre-existing conditions or age, and have the most robust coverage of all our products. All major medical plans require members to be an active participant in their care by engaging with our care coordination team.
Major Medical Copay 3500, Major Medical Copay 4500, Major Medical Copay 8000: These plans are best for those who expect to utilize healthcare services more frequently. Enjoy copays for common services like doctor visits and prescriptions, plus a range of deductible options to control your out-of-pocket costs. If members stay within our Tier 1 Preferred Network they can access $0 care for many services.
Major Medical HSA 5000: This plan is for those interested in having and contributing to a Health Savings Account.
Major Medical Minimum Value Plan (MVP): This plan is best for those who do not expect to go to the doctor frequently and want to have coverage for large unexpected medical costs.
ClearShare Memberships
A healthshare, also known as medical cost sharing, is a nonprofit program that provides an organized structure for a community of members to contribute toward each other’s medical costs.
ClearShare is healthshare; a membership-based community of individuals established for the purpose of sharing eligible healthcare expenses between Members as described in the Member Guidelines. ClearShare is not insurance.
For ClearShare memberships, your effective date is on the first of the next month, or the first of a future month.
You will keep your membership for 1 year after your effective date.
You can only switch memberships (to/from Advanced or Basic) at your 1-year renewal date or during Open Enrollment.
Members may choose to change their Annual Maximum ($1000, $2500, $5000) at your 1-year renewal date or during Open Enrollment.
To cancel your membership, contact members@clearwaterhealth.com. The request must include the reason for cancellation, and the requested month in which the cancellation of the membership is to be effective. ClearShare requires a 30-day notice to cancel a membership. ClearShare does not prorate cancellations or give refunds. Cancellations become effective on the last day of your monthly billing anniversary following the timely receipt of your membership cancellation request.
If you are on an Advanced, Basic, or HSA MEC plan, you must have a Qualifying Life Event (QLE) in order to change or cancel your plan outside of Open Enrollment (November 1-December 31). You have 31 days from the date of your QLE to notify us of the QLE in order to change or cancel your plan. Changes take effect the first of the following month, and cancellations take place at the end of the month.
At the age of 18 a child is eligible to enroll in their own individual membership. However, a child can stay on a parents plan until the age of 26. At the age of 26 or when a child gets married, a child must enroll in their own membership. If someone is 65 or older they are not eligible for a ClearShare membership.
Yes, to add or remove dependents to or from your existing membership, please email planhelp@clearwatersavings.com. Add/remove dependents by the end of the month to be effective the first of the following month. Please see the ClearShare member Guidelines for more information about timelines, monthly contribution changes, and Family Annual Max status.
Yes, however, conception that occurs prior to membership is not eligible for sharing. ClearShare requires notes from the first provider visit in order to verify the conception date.
The ClearShare Member Guidelines are available here: https://clearsharehealth.org/member-guidelines/
No, a referral is not needed. However, we do recommend making sure your provider is in-network.
Yes! Preventive services are shareable with $0 cost to members on our Advanced + ClearShare, Basic + ClearShare, and HSA + ClearShare plans. To learn about the services covered visit https://www.healthcare.gov/coverage/preventive-care-benefits/.
Needs that arise from conditions that existed prior to membership are only shareable if the condition was regarded as cured and did not require treatment for 12 months prior to the effective date of membership. Any illness or injury for which a person has been examined, taken medication, had a diagnostic test performed or ordered by a physician, or received medical treatment is considered a pre-membership medical condition.
High blood pressure, high cholesterol, diabetes (types 1 and 2), hypothyroidism, and hyperthyroidism will not be considered pre-membership medical conditions as long as the member has not been hospitalized for the condition in the 12 months leading up to the effective date and is able to control it through medication and/or diet, as evidenced by lab results/readings within the normal range.
Cancer, heart disease, stroke, and chronic obstructive pulmonary disease (COPD) are only shareable if the condition was regarded as cured and did not require examination, medication, testing, or any other medical treatment for five (5) years prior to the effective date of membership.
If you think you may have a pre-membership medical condition, we encourage you to schedule a call with one of our Expert Benefit Consultants who can help assist you in recommending the best plan based on your needs. Just because you have a pre-membership condition doesn't mean you can't enroll in the Clearwater plans, but further information will be required to determine whether a plan is a good fit for you.
If you think you have a pre-membership medical condition, we recommend booking a consultation with one of our Expert Benefit Consultants.
Pre-membership medical conditions have a phase-in period wherein sharing is limited. Starting from the initial enrollment date, members have a one-year waiting period before pre-membership medical conditions are shareable. After the first year, pre-membership medical condition needs are eligible for sharing on a limited basis, with the amount increasing each membership year.
Shareable amount for pre-membership medical conditions:
- Year One: $0 (waiting period)
- Year Two: $25,000 maximum per need
- Year Three: $50,000 maximum per need
- Year Four: $125,000 maximum per need
After year four of membership, expenses related to pre-membership medical conditions will remain shareable at a maximum of $125,000 in a 12-month rolling period and resetting each membership year.
Advanced + ClearShare, Basic + ClearShare, and ClearShare memberships are not insurance and do not meet ACA requirements.
The HSA + ClearShare plan includes a Minimum Essential Coverage (MEC) plan and does meet the requirements of the ACA.
If you live in a state with an individual mandate requirement and are interested in a ClearShare membership, we can pair a MEC plan with the membership to help you meet the requirement. Book a Call with a consultant to learn more.
If you have a major procedure you are going to schedule, please contact Care Coordination at members@clearwaterhealth.com or 877-405-2926. Care Coordination can help you find a provider and waive your out-of-pocket costs.
For any accident or ER visits, there are no restrictions on providers you can access and you can go anywhere for care. Tell your provider to send bills to us using the information on your member ID card.
To find a list of providers in your area you can go to this website: PHCS Network
When selecting a provider, contact the provider’s office to verify that they are still in-network with PHCS and that the provider’s billing NPI# is contracted through the PHCS/Multiplan network.
For emergencies, there are no restrictions on providers you can access and you can go anywhere for care.
Start with Care Coordination when scheduling major procedures. Care Coordination can help you find a high-quality, lower cost provider. If you use the provider we recommend, your care can be $0. Our team can work with your provider before your appointment to help them understand billing and ensure your appointment runs smoothly.
Use of Care Coordination is required for any pre-planned and non-emergent procedures for the following conditions: Cancer, orthopedic surgeries, cardiac procedures, neuro surgeries, dialysis, transplants, specialized wound care, GI procedures, and prosthetics.
For prompt payment, providers should submit medical bills directly to ClearShare using the information on a member’s ID card.
- Payer ID: DCRSS
- Medical bill address: PO Box 3616, Portland, ME 04104
- Fax: 877-405-3639
Major Medical Plans
You can enroll during open enrollment from November 1 through December 31, or if you have a qualifying life event during the year. If you enroll outside of open enrollment, you will be subject to a 60-day waiting period.
For Major Medical plans, open enrollment is November 1 through December 31. Your plan effective date during open enrollment is January 1. For those that enroll outside of open enrollment, your effective date is on the first of the month following a full 60-day waiting period.
You will keep your healthcare plan until the end of the calendar year, regardless of when you enroll. If there is a qualifying life event, you may be eligible to update or cancel your plan before Open Enrollment.
You can switch plans during Open Enrollment. To switch before then, you must have a qualifying life event.
To cancel your plan, contact planhelp@clearwatersavings.com. In order to cancel your plan, you must have a qualifying life event. You have 31 days from the date of your qualifying life event to notify us of the qualifying life event in order to cancel your plan. Your policy will terminate at the end of the month from the date we receive your qualifying life event documentation.
At the age of 18 a child is eligible to enroll in their own individual plan. However, a child can stay on a parents plan until the age of 26. At the age of 26, a child must enroll in their own plan. If someone is 65 or older they are eligible, however, Medicare will likely be a cheaper option with a broader network.
On the Major Medical HSA 5000 and Major Medical MVP plans, yes. On the Major Medical Copay plans we HIGHLY recommend utilizing care coordination to ensure you are directed to quality providers at a lower cost
Yes! To learn about the services covered at $0, visit https://www.healthcare.gov/coverage/preventive-care-benefits/.
Yes. However, your current providers, treatments and medications may not be covered under the plan. To ensure continuum of care and avoid treatment disruption, schedule a call with one of our Expert Benefits Consultants before enrolling.
Seek care and show your member ID card. For ER visits we request that you notify us within 48 hours of discharge or when reasonably appropriate. If you visit the ER and it is not an emergency you will be subject to a penalty.
Find a participating practitioner/doctor through the PHCS Network for Value-Driven Health Plans. To find a provider, visit: www.hstconnect.com/PHCS.
When selecting a provider, contact the provider's office to verify that they are still in-network with PHCS and that the provider's billing NPI# is contracted through the PHCS/Multiplan network.
Major Medical Copay 3500, Major Medical Copay 4500, Major Medical Copay 8000 plans provide access to Tier 1 In-Network Preferred Benefits. In order to access these benefits for no out-of-pocket cost, you MUST call our care coordination team BEFORE obtaining services. Our Care Coordination team will find you high-quality, lower cost providers for these services. When you use a provider we recommend, your care is completely free.
Care Coordination
Care Coordination access depends on the plan you have selected.
On ClearShare plans, you can use Care Coordination to find providers for labs, imaging tests, some surgeries, and other major procedures. In addition, Care Coordination can help you find local providers if the primary network doesn’t provide the coverage you need in your area.
On Major Medical Copay 3500, Copay 4500, and Copay 8000 plans, Care Coordination is embedded in the plan as a Tier 1 In-Network Preferred provider. Most services other than primary care and emergency services are eligible, but reference your plan documents for a complete list.
When Care Coordination is able to find a provider in your area that we recommend, your care is completely free. Our team will work diligently to find you a recommended provider, however there are instances where no provider is available. Care Coordination benefits are not guaranteed.
On Major Medical HSA 5000 and MVP plans, use of Care Coordination to access benefits or avoid penalty is required for most services. Reference your plan documents for a complete list.
When you need a service that is eligible for Care Coordination, we recommend contacting us at least 21 days before obtaining services. When you choose to see the provider we recommend, your care is completely free.
Our team will work diligently to find you a recommended provider, however there are instances where no provider is available. Care Coordination benefits are not guaranteed.
Care Coordination does not have a doctor lookup. The providers we recommend depend on a variety of factors.
No, Care Coordination works to find and recommend you a fair-priced, high quality provider.
If you want to choose your own provider, you can use your plan’s applicable in-network or out-of-network services.
Do I need to contact Care Coordination for every occurrence, repeat services, or if additional treatment is recommended?
Yes, Care Coordination must be contacted and a provider must be recommended for each service in order to be eligible for waived out-of-pocket costs.
On Major Medical HSA 5000 and MVP plans, use of Care Coordination to access benefits or avoid penalty is required for most services. Reference your plan documents for a complete list.
For other plans, Care Coordination is an added benefit and is not required. If you want to choose your own provider, you can use your plan’s applicable in-network or out-of-network services.
We need orders from your doctor to determine the correct lab/radiology center to recommend you to.
If you are on a ClearShare plan, you first must open a Needs Request online and submit your medical records, including a progress note from your provider, and an order for the procedure.
If you are on a Major Medical plan you should contact your Care Coordination team to find out what documents are required for the service you need.
Call 877-405-2926 or email members@clearwaterhealth.com and ask for Care Coordination.
Brokers
Glossary
Annual Maximum
The annual maximum is the amount that a member will pay before the ClearShare community shares in medical expenses. The annual maximum is also known as your personal responsibility. ClearShare has three primary levels of personal responsibility: $1000, $2500, and $5000. The lower your personal responsibility, the higher your monthly contribution will be.
All qualifying medical expenses submitted after the Annual Maximum is met are shareable with the ClearShare community up to 100% of the usual and customary charge determined by ClearShare. There is no annual or lifetime limit. You will not need to pay the Annual Maximum again until the new calendar year begins. Additionally, you are only responsible for the Annual Maximum once each calendar year.
Service copays are not included in the annual maximum. Members who are also part of an HSA MEC, service related costs that apply to the member’s deductible are not part of the annual maximum.
Dependent
The head of the household’s spouse or unmarried child(ren) under the age of 26, who are the head of household’s dependent by birth, legal adoption, or marriage, and who are participating under the same combined membership. Unmarried children under 26 years of age may participate in the membership as a dependent.
Effective Date
The date a person’s membership begins.
Healthcare Sharing
Healthcare Sharing, also known as medical cost sharing or a healthshare, is a nonprofit program that provides an organized structure for a community of members to contribute toward each other’s medical costs.
Health Savings Account (HSA)
A Health Savings Account (HSA) is a tax-advantaged savings account you can use to pay for qualified medical expenses.
Licensed Medical Professional
An individual who has successfully completed a prescribed program of study in a variety of health fields and who has obtained a license or certificate indicating his or her competence to practice in that field (MD, DO, ND, NP, PT, PA, DC etc.)
Minimum Essential Coverage (MEC)
Minimum essential coverage is the minimum amount of coverage that is considered essential by the Affordable Care Act. Things that are not considered minimum essential coverage include only supplemental plans, coverage for only a specific condition, and worker’s compensation.
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