Operative Rules

Participation is Voluntary

Monthly contributions are voluntary gifts and are not refundable. Each member is a self-pay patient who sends monthly contributions to assist other members who have medical expenses. Whether anyone chooses to share in another member’s medical expenses is totally voluntary. Giving a monetary gift to assist another member in the program does not create a legally enforceable right to receive funds for healthcare expenses. Whether or not any member receives assistance from other members for medical expenses, members are legally responsible for their own medical decisions and the expenses that may accrue as a result of their decisions. They remain ultimately responsible to pay their bill. As a voluntary sharing cooperative, we are constrained by finite resources no matter how many members we have.

MEMBER QUALIFICATIONS AND REQUIREMENTS

Members must be health conscious and wish to maintain their own health and advocate physical, mental and moral fitness as well as help others to do so. They must ascribe to the TEN COMMANDMENTS. Thus members must be able to walk a mile in 30 minutes, not use tobacco, not abuse alcohol or prescription drugs or use illegal drugs, comply with medical therapy for chronic illness.

Existing medical conditions disclosed on an application can help us make suggestions as to lifestyle changes that can improve the health of the individual and benefit the group as a whole. If, at any time, it is discovered that a Member did not submit a complete and accurate medical history on the Medical History Questionnaire, the member’s bills will not be eligible for payment and membership terminated. In such an event, any monies paid will not be refunded. Members may re-apply but acceptance is at the discretion of the Board.

Angels are either regular or prospective members or non-members who make additional payments to help members who are having financial difficulties making the monthly contribution.

Apply to be a Member

Make an appointment for the annual physical exam and submit the first month’s payment. If, on the day of the annual examination, you are not accepted as a member or a prospective member or if you decide you cannot agree with any of the tenants of the group, or if you do not agree to pay the additional fees required of prospective members to help reach agreed on goals, 50% of the initial payment will be returned. You may decide at any later time to leave the group but no monthly contributions will be returned.

MONTHLY SHARE AMOUNTS

The Monthly Payment Amount is determined by majority vote of the Board of Directors and is based upon the amount of bills submitted by members for payment, the amount needed to administer the Program, and the number of participating Members. The Monthly Share Amount may be revised upward or downward as determined by majority vote of the Board of Directors. Notice of such change will be made to the Members in a timely manner, but with no less than sixty (60) days notice.

MEMBER MEDICAL EXPENSES

In general, any medical expenses covered by Medicare may be covered. Home healthcare, Occupational, Speech, Respiratory therapy, Ambulance, Alternative medicine must be approved for sharing by a Doctor Hotline physician or The Houston Healthcare Initiative.

ALL Eligible Sharing amounts will be repriced to 110% of Medicare charges

Expenses NOT Eligible for Sharing

  1. Any medical Bills incurred prior to membership. are not eligible for sharing.
  2. ER charges – Patients should call the Doctor Hotline before going to the Emergency Room. If the doctor advises ER treatment, care is covered at 110% of medicare rates. If the Doctor Hotline is not utilized and the care is not deemed an Emergency, care will not be eligible for sharing. However, if the care is deemed an emergency, it will apply to sharing at 110% of medicare rate.
  3. Expenses where conflicts-of-interest exist, e.g physicians ordering lab or xray at facilities where the physician has a financial interest.
  4. Food or special diets
  5. Injury caused by hazardous hobbies such as bungee jumping, or competitive sports.
  6. Charges for services received as a result of Injury or illness caused by engaging in an illegal act or occupation; by committing or attempting to commit any crime, criminal act, assault or other illegal behavior; including but not limited to illegal drug activity, crimes against persons, crimes against property and gun offenses.
  7. Charges for treatment of injuries or illness while racing or competing as a professional are not eligible for payment. Professional racing means that such activity is one’s primary vocation and means of financial support. Professional racing and competitive events include, but are not limited to, automobile, motorcycle, watercraft, ski or rodeo races or competitions.
  8. Any medical expense due to an intentionally self-inflicted Injury, while sane or insane
  9. Worker’s compensation injury or other work related injury
  10. Auto accidents covered by auto insurance
  11. Prescription drugs over $1000/year not eligible for sharing; Non prescription drug costs are not eligible.
  12. Other Sources of Medical Expense Payment. ​It is the obligation of the member to pursue payment from any other responsible payer for such medical expenses such as free vaccinations for children, Payments from insurance companies or from legal settlements.
  13. Pregnancy is covered only if pregnancy begins 90 days after coverage initiated. The newborn is covered under the plan until the first birthday for free provided both parents are members in good standing and the pregnancy was a covered benefit.
  14. Hospital employees. ​Professional services billed by a Physician or nurse who is an employee of a Hospital or Skilled Nursing Facility and paid by the Hospital or facility for the service.

Members share a responsibility to each other to use the Doctor Hotline to avoid unnecessary services, hospitalizations, and shorten inpatient confinements, while improving quality of care and reducing expenses shared by the members.

DISPUTES

Any disputes over eligible payments must be made in writing within 60 days from the date on the check or date of denial. Coverage will be reconsidered and answered within 60 days of receipt. If there is continued dispute both parties agree to binding arbitration. The three arbitrators will be physicians. Each party will choose their physician. The two physicians will then choose a third. The cost of arbitration will be borne by the losing party. The standard will be within reasonable medical probability.

Texas​ ​Code​ ​Title​ ​8,​ ​K,​ ​1681.001 Notice: This health care cooperative facilitates the payment of medical expenses and is not an insurance company, and neither its guidelines nor its plan of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant will be compelled by law to contribute toward your medical bills. As such, participation in the cooperative or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive any payment for medical expenses or whether this cooperative continues to operate, you are always personally responsible for the payment of your own medical bills. Complaints concerning this health care cooperative may be reported to the office of the Texas attorney general.

MEMBER RIGHTS AND RESPONSIBILITIES

As a Member of Houston Healthcare Initiative you have certain rights and responsibilities. A.​ ​Member​ ​Rights.​ ​You have the right to:

    1. Receive considerate, courteous service from all our employees and representatives;
    2. Receive accurate information regarding program Guidelines and eligibility of sharing in both member literature and when in contact with Houston Healthcare Initiative ;
    3. Have medical expense needs processed accurately once all necessary documentation has been received;
    4. Have all medical records and personal information handled in a confidential manner and in compliance with Privacy Standards;
    5. Be informed about health care practitioners and providers giving discounted services to Sharing Members;
    6. File a dispute when you have one without fear of prejudice or reprisal; and
    7. Make recommendations regarding program Guidelines. B. Sharing Member Responsibilities.

You have the responsibility to:

  1. Read all materials carefully as soon as you receive them and ask questions when necessary;
  2. Regularly check for and review all amendments of and information relating to the Guidelines that may be posted on the Houston Healthcare Initiative website and ask questions when necessary.
  3. Take personal charge of your medical care, and make informed and knowledgeable health care choices;
  4. Learn how to promote and protect your own health and wellness, eat properly, exercise, and eliminate harmful habits, stressors and risk factors within your control.
  5. Seek medical advice when appropriate, including the Doctor Hotline, take the necessary steps to understand the medical advice you receive and any diagnosis you are given, and obtain needed care in a timely manner.
  6. Take the necessary steps to learn about the effects on your body of any medical condition with which you are diagnosed or afflicted and how you can help manage and control the condition.
  7. Steward your own resources and the resources of the membership of Houston Healthcare Cooperative by inquiring about costs prior to obtaining care in all non-emergency situations, make cost comparisons between providers, and make cost efficient choices about the care you obtain. .
  8. Access the Doctor Hotline as needed, when accessing medical care.