Member Handbook

Summary of Membership Sharing Guidelines

SakeOf is a peer to peer community that coordinates voluntary sharing for certain eligible medical bills after verification and fair price review. Participation is voluntary and not guaranteed, does not constitute insurance, and does not create a contract of coverage.

Important disclosure. SakeOf is not insurance. Membership does not guarantee payment of medical bills. Community funding is voluntary and discretionary, subject to eligibility review, documentation requirements, fair price verification, participation status, fraud prevention, and available community funds.

• Notices by participating you also agree to the disclosures and notices posted at Tax information and required notices
• Disputes and decisions sharing and eligibility decisions are made in the sole discretion of SakeOf under the Program Guide and Terms of Service, and are final. Any disputes are governed by the Terms of Service, including arbitration and class action waiver provisions
• Platform growth contribution. The first month of your community ask at enrollment, and the first month of each subsequent year at renewal, is collected by SakeOf as a platform growth contribution to support community expansion, including marketing, onboarding, technology, and broker support. This amount is not deposited into the sharing wallet for sharing needs

Quick start

Use this checklist before and after a medical visit to keep everything moving smoothly.

1. 1Before planned care start an event in the portal and contact Member Advocacy when services may exceed 500 dollars so we can help with fair pricing options.
2. 2At the provider ask for a cash-pay estimate and request itemized billing when available. Always keep your discharge paperwork and provider notes.
3. 3After the visit upload documents promptly. If you receive a balance bill, denial, or final notice, submit it within 10 days of receipt.
4. 4Stay active keep your base fee paid and your wallet funded so your monthly ask can be collected and new events can be considered.

Plans and what they include

• Full Service everyday care and major events, advocacy, bill verification and negotiation, prescription savings, virtual primary care, virtual urgent care, and virtual behavioral health. Items may be considered for community funding after the member commitment, subject to discretionary eligibility and participation requirements
• Major Medical Only focused on large unexpected events with a lower monthly ask cap. Everyday virtual care and prescription savings are included. Items may be considered for community funding after the member commitment, subject to discretionary eligibility and participation requirements
• No networks visit any licensed provider. We help you find fair price options when you want support

Membership fees and monthly caps

• Base membership fee 50 dollars per member per month. This funds advocacy, technology, bill review, and support
• Community ask cap, Full Service
  • Ages 0 to 25, up to 140 dollars per month
  • Ages 26 to 55, up to 220 dollars per month
  • Ages 56 to 65, up to 320 dollars per month
  • Ages 65 and older, up to 420 dollars per month
• Community ask cap, Major Medical Only
  • Ages 0 to 25, up to 110 dollars per month
  • Ages 26 to 55, up to 180 dollars per month
  • Ages 56 to 65, up to 240 dollars per month
  • Ages 65 and older, up to 340 dollars per month
• Households total monthly cap is the sum of each member by age band and selected plan
• One time application fee 100 dollars collected at enrollment
• One time card issuance fee 7.50 dollars per member for the SakeOf wallet and membership card
• Reenrollment fee 125 dollars may be collected if a member reenrolls after cancellation or termination, unless waived in writing by SakeOf
• Fee notice fees are generally non-refundable, may be assessed at SakeOf’s discretion where applicable, and may change with notice as described in this handbook

Platform growth contribution (first month and renewals)

• The first month of your community ask at enrollment is collected by SakeOf as a platform growth contribution
• The first month of your community ask in each subsequent year at renewal is collected by SakeOf as a platform growth contribution
• These contributions support community expansion and operations including marketing, onboarding, technology, and broker support
• These contributions are not deposited into the sharing wallet for sharing needs and are not refundable
• Renewal means your annual membership renewal month based on your original effective date, not your monthly billing date

Select household size

• Members of the same household joining the same membership must be related by birth, marriage or adoption
• An unmarried dependent child may participate with his or her parent(s) or legal guardian(s) under a sharing membership up to and including age 26
• Unmarried dependents may continue as sharing members with their parent or guardian if they are medically unable to maintain a full-time occupation or be a full-time student because of illness or injury, physical or mental disability. A physician or qualified health professional may be required to verify this disability
• It is the member’s responsibility to notify SakeOf of any change in the marital status of their dependent child that may affect continued participation as a dependent of the member. If marital status is not as presented at the time an episode of care is submitted for sharing, such medical expenses will not be eligible for sharing
• Dependent who wishes to continue membership but who no longer qualifies due to age or marital status must apply and qualify on his or her own merit as a new sharing member. If the dependent applies and is accepted within 30 days of the loss of qualification, the membership enrollment dues are waived. If the dependent has a medical condition when he or she applies as a separate SakeOf member, any existing medical conditions will be eligible for sharing with no interruption of his or her sharing member status
• A newly adopted child may be added as a dependent to a membership provided all medical criteria be met within the program for acceptance. The sharing member must provide notification of adoption, including all medical history or existing conditions, in writing within 30 days after finalized adoption. Existing medical conditions disclosed for a dependent may result in a declination, or a limitation on the types of needs eligible for sharing
• In the event of divorce or separation where the primary member and spouse desire to continue as SakeOf members, both parties must notify SakeOf. The original combined membership will be cancelled, and a new membership created for each party. Both members will keep their original effective date and the first-time membership enrollment dues will be waived. Each new membership is subject to the new ask caps and program limitations

Member commitment per event

• Full Service 500 dollars for a standard health event and 5,000 dollars for maternity
• Major Medical Only 15,000 dollars for a standard event
• After you meet the member commitment, the remaining balance may be considered for community funding subject to discretionary eligibility review, participation requirements, and available community funds
• Community funding is discretionary even if an item appears eligible, the community may decline or partially fund a request for reasons including eligibility results, pricing review, documentation requirements, participation status, fraud prevention, or available community funds

What is eligible

• Medically necessary services for illness or injury
• Emergency and urgent care
• Diagnostics, labs, and imaging
• Hospitalization and surgery
• Ambulance when medically necessary
• Therapies when ordered by a licensed provider
• Maternity when eligible by plan and waiting period
• Items pass eligibility review and fair price verification

How it works

1. 1Choose any licensed provider. For planned care or services estimated at 500 dollars or more, contact us in advance when possible so we can help with navigation and fair pricing
2. 2If a visit is under 500 dollars, you are responsible for payment because it is below the Full Service member commitment. Ask for an itemized bill and a cash-pay estimate when available
3. 3For services 500 dollars or more, the provider should bill through the SakeOf membership card process. If the provider needs eligibility verification or billing support, have them call the phone number on the back of your card
4. 4SakeOf reviews medical necessity and fair pricing. After you meet the member commitment and remain active and current on community asks, the remaining balance may be considered for community funding subject to eligibility review, documentation requirements, fair price verification, participation status, fraud prevention, and available community funds. Funds may be sent to your SakeOf wallet or paid to the provider where accepted

Prenotification of medical expense

Prenotification is a process by which SakeOf assists members to determine eligibility for submission of upcoming medical services and procedures, in accordance with their program and member handbook. Providing sufficient advance notice, whenever possible and as required, is a responsibility of the member. SakeOf can offer a range of recommendations to assist members with avoiding unreasonable billing practices by some physicians and facilities. While our processes don’t dictate a member’s medical treatment choice, they are designed to assist members in navigating the complexities of the healthcare system.

Documentation and deadlines

To evaluate eligibility and coordinate funding, we may require documents from you and your provider.

• Itemized bill required for all submissions and must include service dates, CPT/HCPCS when available, and provider information
• Medical records may be required to confirm clinical details or medical necessity
• Submission timeline submit complete documents within six months of date of service
• Urgent notices submit any balance bill, denial, or payment demand within 10 days of receipt
• Authorization you may be asked to sign medical record release forms to allow SakeOf and its vendors to obtain required documentation
• Incomplete submissions requests may be paused, limited, or denied if required documents are not received within a reasonable timeframe

HIPAA, PHI, and personal information

SakeOf may need to request and use certain health and billing information to evaluate eligibility, support fair price review, and coordinate program operations. This section explains how we handle protected health information and personal information, and what you authorize as a condition of participation.

Protected health information (PHI)

• What we may request. We may request medical records, clinical notes, provider documentation, diagnosis and procedure details, and billing records needed to verify eligibility, confirm medical necessity when required, and support fair price review and negotiation.
• How we may use PHI. We use PHI for program operations including eligibility verification, medical necessity review when applicable, fraud prevention, billing support, care coordination, case management, provider negotiation, appeals or reconsideration review, quality assurance, and dispute resolution.
• How we may disclose PHI. We may disclose PHI to contracted vendors and service providers who support these operations (such as bill review and negotiation partners, pharmacy and telehealth partners, payment and wallet providers, identity verification providers, and technology vendors) as necessary to perform services on our behalf.
• Safeguards. Vendors are required to protect information, limit use to authorized program operations, and apply appropriate administrative, technical, and physical safeguards. We limit access to those with a need to know for program operations.
• Member authorization. By participating, you authorize SakeOf and its vendors to request, receive, store, review, and use PHI and related documentation to administer your membership, evaluate eligibility, and coordinate voluntary sharing, including to communicate with your providers on your behalf where required.

Personal information (PII)

• What we collect. We may collect personal information such as your name, contact information, date of birth, address, household information, payment information, identity verification data, and account and device information used to operate the portal and wallet.
• How we use PII. We use personal information to manage your account, provide customer support, process payments and participation asks, prevent fraud, comply with legal obligations, communicate with you, and improve program operations.
• Sharing and service providers. We may share personal information with service providers who help operate the program, including payment processors, wallet providers, identity verification providers, communication providers, and technology vendors, subject to confidentiality and security safeguards.
• Security. We use reasonable administrative, technical, and physical measures designed to protect personal information. No system can be guaranteed to be completely secure, and members are responsible for protecting login credentials and promptly reporting suspected unauthorized access.

Policies that support fairness and participation

Price fairness policy

• SakeOf targets fair market cash pricing in your region
• For planned care we may request a second option when a quoted price is well above fair market levels
• Bills that reflect unreasonable pricing may have limited eligibility until negotiation completes
• If a member declines reasonable alternatives or refuses required documentation, the request may be denied or limited

Fraud prevention and integrity

• SakeOf may verify identity, participation status, and provider credentials to prevent fraud
• Misrepresentation, falsified documents, altered bills, or intentional omissions may result in denial and account restriction
• SakeOf may request additional information if an event is unusual, inconsistent, or requires deeper review

Participation policy

• Requests to fund others are voluntary
• Consistent participation helps stabilize monthly asks for the community
• The program relies on consistent voluntary participation to promote stability and timely sharing across the community
• To be eligible for community funding you must keep your membership active. Active means your base fee is paid, your wallet is funded with the current month’s community ask, and any past due asks are made current
• If you are not active or not current on your asks, new medical events are not eligible for submission or funding until your participation is brought up to date
• Platform growth contribution. The first month of the community ask at enrollment and the first month of the community ask each year at renewal is collected by SakeOf for platform growth and community expansion, including marketing, onboarding, technology, and broker support, and is not deposited into the sharing wallet for sharing needs

Pre-existing conditions and waiting periods

Definition. A pre-existing condition is any illness, injury, symptom, diagnosis, or treatment that existed, was advised, was known, or for which medical advice, diagnosis, or care was recommended or received during the 24 months prior to your membership start date. Related conditions may be treated as one event. Eligibility determinations are discretionary and based on documentation, clinical review, and the Program Guide.

• Months 0 to 12 not shareable
• Months 13 to 24 up to 25,000 dollars per year
• Months 25 to 36 up to 50,000 dollars per year
• After 36 months fully shareable

Wellness and virtual care

• 24/7 nationwide urgent care telemedicine visits at no cost to you
• Acute prescriptions with 70 commonly used drugs free at more than 60,000 pharmacies, with no limits on dose, duration, or frequency when clinically appropriate
• On demand virtual counseling with masters level counselors, with unlimited sessions
• These virtual and wellness services are included for both Full Service and Major Medical Only members. Wellness and screening services may be guided to fair price options, and some items may not be eligible for community funding

Pharmacy

• Use prescription savings tools provided by SakeOf when available
• Choose generic options when clinically appropriate
• Maintenance drugs are generally limited to a twelve month supply per membership life. If you need expanded maintenance medication support, ask Member Advocacy about optional pharmacy upgrade programs and pricing. View optional pharmacy upgrades

Maternity and family

• Maternity eligibility per plan with a waiting period
• Maternity waiting period. Maternity-related requests are eligible only if the member has been active for 10 months prior to conception, is current on asks, and meets documentation requirements
• Newborn must be added within thirty days of birth to enable funding from the date of birth
• Family totals use each member age band and plan to calculate the monthly cap

Member responsibilities

• Keep membership active by paying the base fee each month and staying current on monthly asks and any past due amounts
• Maintain a valid payment method and load your wallet so that your monthly ask can be collected
• Pay your member commitment when it applies
• Submit complete and itemized bills within six months of the date of service. Requests submitted after the deadline may be denied
• Submit any balance bill, denial notice, or request for payment received from a provider within 10 days of receipt so we can review, negotiate, and correct billing issues
• Notify SakeOf for planned care so we can assist with navigation and negotiation

Admin and late fees

• Late payment 15 dollars
• Reactivation 25 dollars
• Returned payment 25 dollars
• A payment is considered late after we attempt automatic retries for a few days and the payment still does not complete. Once a payment is late, a 25 dollar returned payment fee applies when the payment fails and your account may be restricted until brought current

Exclusions

• Cosmetic or elective services
• Services that are not medically necessary
• Items outside published limits or categories
• Illegal or fraudulent activity
• Experimental items that lack evidence of benefit
• Services primarily for comfort, convenience, personal preference, or lifestyle choice, including non-medically necessary upgrades or amenities
• Routine, preventive, screening, or wellness services unless specifically included by plan or approved in advance
• Dental, orthodontic, vision, and hearing services unless medically necessary due to illness or injury and approved as eligible
• Fertility services, infertility evaluation, assisted reproductive technologies, and elective contraception, unless required for medically necessary treatment of an illness or injury and approved as eligible
• Weight loss programs, nutritional supplements, and obesity-related medications or procedures unless medically necessary for treatment of a covered illness or injury and approved as eligible
• Services, supplies, or devices not ordered by a licensed provider, including over the counter drugs and supplements unless explicitly approved
• Alternative, complementary, or investigational care that lacks sufficient clinical evidence of benefit, unless ordered by a licensed provider and approved after review
• Services received outside the United States, medical tourism, and associated travel expenses unless approved in advance and deemed medically necessary
• Injuries or conditions resulting from participation in illegal acts, fraud, or intentional misrepresentation
• Self-inflicted injury or harm, including attempted suicide, except where prohibited by applicable law
• Costs that are eligible for payment or reimbursement through workers’ compensation, auto insurance, liability claims, government programs, or other coverage may be excluded or reduced unless and until those sources are exhausted
• Any expense or balance bill arising from failure to provide required documentation, refusal to cooperate with eligibility or fair price review, or failure to follow reasonable clinical guidance necessary to resolve the event
• Occupational or work-related injuries or illnesses, including self-employment, are not eligible for sharing, unless the state in which the injuries occurred has no workers’ compensation laws or requirement, or state laws do not require the business owner and or enterprise to participate in workers’ compensation. Documentation may be required
• Breast implants including the placement, replacement or removal of breast enhancement devices and complications related to breast implants unless related to reconstructive mammoplasty
• Alcohol or drugs services, supplies, care or treatment for an injury and or disease and or bodily malfunction that occurred as a result of abuse and or use of alcohol or drugs or pharmaceuticals, including drug and or alcohol rehabilitation treatment
• Emergency room charges when not an emergency when treatment at an emergency room is not determined an emergency by normal standards of medical care and when less costly treatment was available by taking reasonable measures to seek such care
• Eye care including eye exercise therapy, radial keratotomy or other eye surgery to correct nearsightedness or farsightedness or any other vision problems that could be corrected with corrective eyewear; routine eye examinations, including refractions, lenses for the eyes and exams for their fitting. This exclusion does not apply to the initial permanent lenses following cataract removal. Ineligible optometry. Routine vision exams or any treatment related to vision correction. Eligible ophthalmology. Treatment of disorders and diseases of the eye not routinely vision correction related
• Gastric bypass, gastric sleeve or other types of bariatric or weight loss surgery are not eligible for sharing
• Gross negligent acts, hazardous activities, illegal acts and self-inflicted injury. Expenses resulting from an illness or injury where the member has acted with gross negligence or with reckless disregard to safety, as evidenced by medical records and as determined by SakeOf. Care and treatment of an injury or illness that results from engaging in a hazardous activity is not eligible for submission. An activity is hazardous if it is an activity which is characterized by a constant or recurring threat of danger or risk of bodily harm. 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 illegal drug activity, crimes against persons, crimes against property and gun offenses is not eligible for submission. Any medical expense due to an intentionally self-inflicted injury, while sane or insane is not eligible for sharing
• Non-compliance with medical advice including failure or refusal to comply with physician treatment plan and or leaving a facility against medical advice shall be subject to clinical review and may result in a determination of ineligibility for submission
• No obligation to pay charges incurred for which the sharing member has no legal obligation to pay are ineligible for submission
• Outpatient pharmaceuticals including maintenance pharmaceuticals regardless of the route of administration and over the counter medications whether prescribed or not are not eligible for submission, but may be eligible for discounts under pharmaceutical discount programs that SakeOf may offer
• Outpatient prescribed or non-prescribed medical supplies including over the counter drugs and treatments, nutritional formulas regardless of age, elastic stockings, tubing, masks, ostomy supplies, insulin infusion pumps, ace bandages, gauze, syringes, diabetic test strips and similar supplies are ineligible for submission
• Personal comfort items such as air conditioners, air-purification units, humidifiers, electric heating units, orthopedic mattresses, blood pressure instruments, scales, elastic bandages or stockings, nonprescription drugs and medicines, first-aid supplies and non-hospital adjustable beds are ineligible for submission
• Relative providing services professional services performed by a person who ordinarily resides in the sharing member’s home or is related to the sharing member as a spouse, parent, child, brother or sister, whether the relationship is by blood or exists in law are ineligible for submission
• Replacement braces of the leg, arm, back, neck, unless there is sufficient change in the sharing member's physical condition to make the original device no longer functional are ineligible for submission
• Sports-related safety or performance devices and programs, and all membership, registration, or participation costs related to physical conditioning programs such as athletic training, bodybuilding, exercise, fitness flexibility and diversion or general motivation are not eligible for submission
• War, military activity or intentional involvement in terroristic action or civil unrest including riots, violent protests or civil disobedience are ineligible for submission

Eligibility and enrollment

• Open to adults eighteen and older who meet participation criteria. Minors may enroll as members with an adult guardian who manages the account and wallet on their behalf. Rules may vary by state and plan
• Rules may vary by state
• Medical information consent. Members authorize SakeOf and its vendors to request, receive, review, and store medical and billing records necessary to evaluate eligibility, negotiate fair pricing, administer the membership card process, and prevent fraud. Members may be required to provide documentation and sign authorizations as a condition of consideration for community funding

Account wallet and payments

• Each member receives a SakeOf wallet and membership card. Your wallet has a participation balance that you load for your monthly asks and fees, and a funding balance where approved community funds may be deposited
• Wallet ownership and control. The wallet is owned and controlled by the designated primary member of the membership. KYC is required to open the wallet account at the time of membership
• Platform growth contribution. In the first month of enrollment and in the first month of each renewal year, the monthly community ask is collected by SakeOf as a platform growth contribution and is not deposited into the sharing wallet for sharing needs
• Authorization. Members agree to allow SakeOf to move funds on their behalf for the purposes of paying platform fees, membership fees, medical bills, negotiated settlements, refunds, chargebacks, returned payments, and any other liabilities in regards to their account
• Funds for approved items may be sent to the funding balance in your SakeOf wallet or paid directly to providers where accepted. Funding balances may be limited to eligible medical and related expenses
• Use your SakeOf membership card for approved transactions and for services where we are securing fair pricing, especially when bills are 500 dollars or more
• If a negotiated price is reduced after payment members agree in good faith to return excess funds to the community
• Community funding is discretionary. Even if an item appears eligible, the community may decline or partially fund a request for reasons including eligibility results, pricing review, documentation requirements, participation status, fraud prevention, or available community funds

Changes cancellation and reinstatement

• You may change plans. Changes apply to new events. Events tie to the plan in effect when symptoms began
• You may cancel any time. Cancellation is effective at the end of the current billing cycle
• If you cancel, SakeOf may use any remaining account or wallet balance to pay submitted needs, medical bills, and related liabilities incurred between the date of cancellation and the end of the billing period, subject to program rules and discretionary eligibility review
• If a payment remains late for more than sixty days your membership is cancelled and you must reenroll to participate again. The same applies if you cancel your membership. Any waiting periods, timers, and eligibility periods restart upon cancellation and reenrollment
• Reinstatement may require a waiting period and payment of any fees

Pricing and ask cap adjustments

SakeOf may update membership pricing, base fees, and monthly ask caps over time to support operations and ensure the community can continue funding eligible needs.

How adjustments may work

• If SakeOf experiences two consecutive months where collected funds are insufficient to cover operating expenses and verified eligible funding needs, SakeOf may adjust monthly ask caps and or base fees beginning in the third month
• Adjustments may also be made due to changes in medical costs, utilization, operating costs, fraud risk, regulatory requirements, payment processing costs, or other business needs
• Changes apply prospectively and do not change eligibility decisions for prior events already submitted under previous terms

Notice

• When possible, SakeOf will provide advance notice through the portal, email, and the upcoming changes page (link top of the page)
• The most current terms and updates are always reflected in the published Program Guide and the upcoming changes page

How to get the most from your membership

• Start events in the portal before planned care when possible
• Ask for itemized bills and cash estimates
• Use your SakeOf card and navigation to compare options and secure fair prices, especially when care is expected to cost more than 500 dollars
• Upload documents promptly and respond to requests from the team

FAQ

Definitions

• Active membership means your base fee is paid, your wallet is funded for the current month’s community ask, and any past due asks are made current.
• Community ask is the monthly amount collected to support eligible funding needs, capped by age band and plan.
• Member commitment is the portion of an eligible event that the member pays before community funding may be considered.
• Eligible means the item passes discretionary eligibility review and fair pricing verification under the Program Guide.
• Event refers to clinically related services connected to the same condition, injury, or pregnancy, which may be reviewed as a single submission.
• Fair price refers to a reasonable cash-pay amount in the member’s region based on common market pricing and provider type.
• Primary member is the designated account owner who controls the membership wallet and is responsible for participation and communications for the membership.
• Household means members on the same membership who are related by birth, marriage or adoption and meet dependent qualification rules described in this handbook.
• Renewal means the annual membership renewal month based on the membership effective date.

Contact

Need help with billing, eligibility, provider questions, or pharmacy options? Contact Member Advocacy.