How CFMS CommunityCare Works

No, It’s Not Health Insurance – and Why That’s a Good Thing

One of the biggest questions we get is, “How is CFMS CommunityCare so much cheaper than other health insurance?” And the answer is simple: CFMS CommunityCare isn’t health insurance. It’s a platform, community, and toolkit to help you find and fund your healthcare outside the insurance system, including a healthcare crowdfunding platform for your big bills. This means your Membership is designed and funded differently than health insurance, and that CFMS CommunityCare has different priorities (like putting you, our Member, first!).

We have developed systems and processes that allow the Community to fund medical expenses; however, your Membership is not insurance, and therefore CFMS CommunityCare cannot guarantee that your medical bills will be funded. Ultimately, Members are responsible for their own medical bills.

What Members Pay

Advocacy Fee Payments and Monthly Crowdfunding Requests

Compared to painfully expensive insurance premiums, CFMS CommunityCare Members pay a low, monthly Advocacy Fee to have access to cash-pay resources and specialized support, as well as commit to helping fund other Members’ medical bills each month. Advocacy Fee amounts are the same for everyone, and monthly crowdfunding maximums are different based upon anticipated healthcare needs of certain age groups. Here’s how it breaks down:

MEMBERS AGES 0-54

• ADVOCACY FEE - $55 PER MONTH 

• FOR CROWDFUNDING - UP TO $140 PER MONTH 

• MEMBER COMMITMENT - $500*

*Amount paid by Member per unique health event before expenses are eligible for funding by the Community. 

MEMBERS AGES 55-64

• ADVOCACY FEE - $55 PER MONTH 

• FOR CROWDFUNDING - UP TO $280 PER MONTH 

• MEMBER COMMITMENT - $500*

*Amount paid by Member per unique health event before expenses are eligible for funding by the Community. 

FAMILIES OF 4+

• ADVOCACY FEE - $55 PER MONTH PER MEMBER

• FOR CROWDFUNDING - UP TO $420 PER MONTH PER FAMILY 

• MEMBER COMMITMENT - $500*

*Amount paid by Member per unique health event before expenses are eligible for funding by the Community. 

NOTE: Members in Colorado can opt out of Advocacy fees but will lose access to Personal Care Advocacy, Bill Negotiations, the CFMS CommunityCare App (including virtual urgent and primary care, virtual talk therapy, and discount prescriptions). Members opting out of advocacy fees are required to mail in their bills for crowdfunding, which are subject to a 20% administrative fee. Please contact hey@CFMSCommunityCare.com if you would like to learn more about this option.

More About Crowdfunding

The maximum monthly crowdfunding amounts listed above are not fixed and can be adjusted based on the actual spending of you and the Community. If you and the Community spend less in a given month, your total monthly crowdfunding request may be lower. Making healthy and smart spending choices benefits both you and the whole Community together.

At the beginning of every month we will provide an estimate of how much each member will be asked to contribute in that month. However, members might be asked to give slightly more or slightly less than the estimate, given the timing and dollar amount of the bills submitted for crowdfunding. Not all members will give the same amount each month but the variation will be small. 

When you or someone in your family turns 55, the maximum crowdfunding amount will increase to $280 on the first billing date following the birthday.

If you’re 64 years old, we’ll be in touch with you before your next birthday about transitioning out of CFMS CommunityCare. Your Membership ends when you turn 65.

Transparency in Crowdfunding

Choosing to help other Members pay their medical bills is voluntary. To help you understand who and what you’re being asked to fund, each Member receives a Generosity Score, and each crowdfunding expense receives a Health Cost Score. These factors determine whether a crowdfunding request is rated GREEN or RED.

Member Generosity Scoring

Member Generosity Scores are calculated based on the amount a Member has given in crowdfunding, compared to the total amount they have been asked to give.

If you agree to fund 100% of the fair-priced crowdfunding requests you receive, you will maintain a 100% Generosity Score. If you choose not to participate in funding other Members’ fair-priced bills, your Generosity Score will be affected by the proportion of what was requested of you versus what you gave. 

A Generosity Score of less than 90% will lead to a RED rating of your crowdfunding request.

Bills that are scored red due to a low generosity score and are not fully funded by the Community in the first crowdfunding request can be rerun through crowdfunding as green once the member’s generosity score reaches 90% so long as the date of service on the bill is less than 12 months old. 

Health Cost Scoring

CFMS CommunityCare’s navigation services help Members access quality care and ensure that crowdfunding requests reflect reasonable cash-pay pricing. If you need a surgery or other scheduled procedure, treatment, or diagnostic (including labs and imaging) we can compare estimates from other providers and offer competitive rates for high quality care.

If you pick a provider that charges more than 120% of the fair market price for the treatment or procedure, the expenses will receive a poor Health Cost Score and lead to a RED rating of your crowdfunding request.

Please note that Health Cost Scoring applies not just to large/expensive planned procedures, but also to smaller expenses like labs and imaging. Please contact your Care Advocate before having any scheduled diagnostic, lab, imaging, or other planned test done, and we will gladly help you shop, and when available connect you with a discount voucher for the same service in your area. Failure to notify CFMS CommunityCare before costs over 120% of our discount options are incurred will result in a RED rating of these bills.

Staying GREEN

The following factors contribute to a GREEN crowdfunding request rating:

• The requesting Member has Generosity Score of 90% or above;

• Health costs for the request are within 120% of fair market rates, considering factors like:

1. Previously crowdfunded procedures in the Member’s regional market within the last year,

2. Third-party partner securing a single-case agreement (SCA), cash-pay bundle, or discount voucher,

3. No reasonable alternatives within the nearest major metro area of home ZIP code for procedures under $10,000,

4. No reasonable alternatives within 1000 miles of home ZIP code for procedures equal to or more than $10,000,

5. Medically urgent, critically time-sensitive, or emergency event, or

6. Extenuating circumstances.

• In the case of travel to a provider navigated by CFMS CommunityCare, all travel expenses including airfare, rental car/mileage, hotel, and food are eligible to be submitted to the Community.

If you are a generous Member, and your healthcare costs are in line with fair-market rates, your crowdfunding requests will be rated GREEN, which tells your fellow CommunityCare Members they can have peace of mind in funding your request.

Avoiding RED

Reasons an expense may receive a RED score include:

• The requesting Member has Generosity Score below 90%;

• Price is more than 120% of fair market rates, when compared to other options identified by CFMS CommunityCare;

• Choosing a non-medically necessary, experimental, or non FDA approved option for care, without demonstrably better patient outcomes in comparison to other options for treatment, as determined by a third-party clinical review;

• Failure to take advantage of negotiated discount, e.g. due to Member negligence or unresponsiveness;

• Paying inflated prices for care through an insurance plan or toward a deductible; or

• Failing to cooperate with CFMS CommunityCare in the negotiation of medical bills or failing to comply with negotiated payment terms.

If you are not generous to other Members in need, OR your healthcare costs are out of line with fair-market rates, your crowdfunding requests may be rated RED, which may cause fellow Community Members to hesitate in funding your request.

Members will not be penalized for denying crowdfunding requests rated RED.

Crowdfunding Request Settings

Most Members choose to help with every GREEN crowdfunding request, which makes things easy and keeps your Member Generosity Score at 100%.

The default settings for crowdfunding are to immediately approve GREEN requests and immediately deny RED requests. (Your generosity score is not negatively impacted by denying RED requests.) 

If you would like time to review crowdfunding requests before paying them, you may change your settings within the mobile app. Turning the default settings OFF will give you two days to respond to a crowdfunding request. If you do not manually respond to the request within those two days, green requests will be automatically approved and your card on file will be charged. Because these funds go directly to other members, they are non-refundable. Red requests will be automatically denied.

When you approve a crowdfunding request, your payment method on file will be charged for the requested amount.

Family Memberships

Family Memberships are available for families with four or more Members. To be eligible for a Family Membership, you must meet at least one of these conditions:

• A parent, under age 65, with three or more children, by legal and/or blood relation, who are under age 26;

• Two parents domiciled together, under age 65, with two or more children, by legal and/or blood relation, who are under age 26;

Member Commitments Instead of Deductibles

The Community exists without the burden of an annual health insurance deductible.

Insurance deductibles can mean you pay $3,000, $5,000, or even $10,000+ in health expenses for your family, on top of those high monthly premiums, before your coverage kicks in at all.  After your deductible is met for the year, you may continue to pay a percentage of the costs up to an out-of-pocket maximum that’s much higher than your deductible. Ouch!

CFMS CommunityCare is different. Your Membership means you commit to your fellow Community Members that you’ll pay your $500 Member Commitment for each valid health event, and we’ll ask the Community to fund the rest of the eligible expenses. There is no maximum limit to the amount of bills you can submit for crowdfunding as a CFMS CommunityCare Member.

What Do You Mean by “Health Event”?  

A health event is any unique health scenario that comes up for a Member and includes all the expenses related to it. It could be something big, like a knee surgery (which might entail doctor’s visits; the surgery itself including physician’s fees, facility, and anesthesia; physical therapy; and pain meds) or something minor, like one of your kids needing to see the pediatrician for a sore throat.

With each valid health event, Members pay the first $500 as your Member Commitment. For many health events, your bill(s) will total much less than $500 – for example, a standard doctor’s visit and prescription for strep throat will cost you much less than $500, so this isn’t something you would submit for crowdfunding. But, for larger events, like the knee surgery example above, you’ll pay the initial $500, and all valid expenses over your Member Commitment will be submitted to the Community for funding.

For health events lasting longer than twelve months (starting with the original date of service for the visits and bills in the event), the $500 initial Member Commitment will reset in the thirteenth month.

Our Commitment to Revenue Transparency

Some of the main factors in rising healthcare costs are the mismatched incentives built into the system’s financial structure: health insurance companies profit off a percentage of customer premiums, so they can make more money by hiking up prices.

CFMS CommunityCare is different. We have intentionally established our revenue to align our incentives 100% with the goals of the Community, and we’re committed to being transparent about it.

CommunityCare receives revenue from Members’ Monthly Advocacy Fees. Since CFMS CommunityCare doesn’t make money as a percentage of crowdfunding, we have no interest in denying the crowdfunding of Members’ bills to increase our profits. We are here to help you and the Community save, always.

Using Your Membership

Membership Basics

Membership Accounts and Crowdfunding Bank Accounts

CFMS CommunityCare Primary Members will have both a Membership Account and a Crowdfunding Bank Account in order to be an active Member of CFMS CommunityCare. Your Membership Account involves the information you enter during the online signup process. Your Crowdfunding Bank Account is an FDIC insured bank account that enables the sending and receiving of crowdfunded monies between Member crowdfunding accounts and for the payment of healthcare services. 

Getting Oriented

Because CFMS CommunityCare is different, we want to make sure Members understand the tools that help you navigate your healthcare without insurance. To help you get the most out of your Membership, CFMS CommunityCare requires the Primary Member to complete a short New Member Orientation video and quiz. You will receive an email with a link to the Orientation video and quiz on the day your Membership starts. 

Notifying Us of Your Events

For your healthcare to be eligible for funding by the Community after your $500 Member Commitment is met, you must initiate your health events through the CFMS CommunityCare mobile app. A Care Advocate will assist you and gather additional information to help you through your health event.

Members should initiate all planned care through the platform, regardless of whether it is expected to exceed the $500 Member Commitment. That way, your bill payment process is kept simple, and your Care Advocate can support you along the way.  Even if you need care that isn’t eligible for crowdfunding, we can still help navigate you to fair prices and high-quality care. If multiple Members of your family are involved in the same health event, like both kids getting the flu the same week (hang in there!), you’ll need to open separate health events for each person, and each person’s care will be subject to a separate $500 Member Commitment.

Choosing Your Doctor

CFMS CommunityCare does not participate in a provider network. You can see your existing doctors, or let your Care Advocate know if you need help finding a new one.

For your healthcare to be eligible for crowdfunding, it must be performed by a licensed or board-certified practitioner. 

To uphold the integrity of the crowdfunding process on behalf of the Community, Members should not knowingly or repeatedly visit a medical practitioner who is unreasonable or unfair in their billing rates and practices.

Submitting Your Bills & Receipts

When you receive a bill, scan it into the CFMS CommunityCare app and attach it to your health event. If your bill needs to be negotiated, we’ll coordinate with our partners to help you get the best discounts.

Once all necessary information has been uploaded, we will review and submit approved bills for crowdfunding quickly and easily.

Handling Big Bills

The CFMS CommunityCare platform is designed to maximize the probability that all Members’ eligible bills can be fully crowdfunded.

For big, planned expenses (like surgeries), CFMS CommunityCare can make sure your estimate is GREEN and find other options for care if necessary, oftentimes saving you 30-80%! Always contact your Care Advocate before a scheduled surgery to allow time for this negotiation.

For emergency expenses, CFMS CommunityCare provides specialized post-negotiation support to work down balances before they are paid, sometimes up to 95% off. Contact your Care Advocate before you pay a big bill for emergency care, so we can help.

Online Platform and Mobile App Access

As soon as you sign up for your CFMS CommunityCare Membership, you can download and log into the CFMS CommunityCare mobile app (after 1/1/2025) and will be able to access your Member Portal through the website (after 12/1/2024). Because our app and portal contain information and tools that are reserved for active and oriented Members, you will not be able to utilize the full app functionality until your Membership start date. Please note that without access to our app via a smart device, you will not be able to utilize certain features of your CFMS CommunityCare Membership.

If you have any questions or issues with logging in or accessing the Member Portal or the CFMS CommunityCare mobile app, please email us hey@CFMSCommunityCare.com 

Self-Pay Patient Status

CFMS CommunityCare isn’t insurance, so you do not have an ID card, Member number, or benefits group to submit on patient intake or other insurance-type forms.  At any medical visit, you’ll just indicate that you are an uninsured, or "self-pay" patient.

Health Event Specifics

Virtual Care

Because the CommunityCares about your well-being and wants to encourage access to high-quality healthcare when you need it, virtual visits – including services like virtual urgent care, virtual primary care (VPC), and virtual talk therapy (including teen and couples talk therapy) -- through the CFMS CommunityCare mobile app. For virtual primary care and virtual urgent care, payment is required at the time of service and these visits are fully “crowdfund-able” once you submit your receipt. For virtual talk therapy, there is no upfront payment required. CFMS CommunityCare will automatically generate a crowdfunding request for your virtual talk therapy visits.

Annual Wellness

CFMS CommunityCare Members can submit up to $300 for ONE basic wellness event per year to be crowdfunded. This wellness event can be utilized for any one of the following, performed by a licensed or board-certified practitioner:

• primary care wellness exam/physical, including naturopathy from a qualified practitioner;

• pediatric well-child visits;

• direct primary care (DPC) membership fee;

• annual female gynecological exam and labs;

• dental exam, including cleaning and X-rays; or

• vision exam and corrective lenses.

• annual dermatological skin check

• annual wellness check with a specialist

CFMS CommunityCare Members age 18+ can also submit one CFMS Biomarker panel for $199 per year to be crowdfunded.

The Community waives the $500 Member Commitment for one annual wellness event per Member (ages three and over) and one CFMS Biomarker panel per Member (ages 18+). Annual wellness spending beyond these crowdfunding thresholds will be funded by the Member. 

Please note that if after a basic wellness event, your doctor orders specialized diagnostics, imaging, additional lab work, or other follow-up care related to a new concern or acute condition identified at your wellness visit, that will initiate a new, separate health event and will be subject to the $500 Member Commitment.

Certain other preventive care, e.g. colonoscopies and mammograms, are valid health events and are separate from the basic wellness event described above. Expenses related to these wellness events can be navigated by your Care Advocate and submitted for crowdfunding when the $500 Member Commitment has been met. Beyond these specific diagnostics and the single annual wellness visit and CFMS biomarker panel, all other preventative care is the full responsibility of the Member and is not eligible for crowdfunding. Talk to your Care Advocate about how to make the most of your annual wellness crowdfunding.

Your wellness care must be completed by December 31 to apply for that calendar year.

Given the frequency of recommended well checks for our littlest Members, health events for Newborn and Children’s Wellness are treated differently up to three years of age. See “Caring For Your Family” below.

Scheduled (Non-Emergency) Care

For all non-emergency care, you'll log your visits through the mobile app before you go, which lets your Care Advocate give you personalized care and support throughout the process.

For minor appointments, notify your doctor that you are a self-pay patient and pay the doctor at the time of your visit.

If your doctor requests labs, imaging, or other follow-up care, please get the orders from your doctor at your appointment and send them to your Care Advocate, who can help you navigate the next steps with high-quality care and fair pricing.

For major non-emergency care, such as a scheduled surgery, please contact a Care Advocate prior to scheduling. To validate potentially expensive and/or complex health events on behalf of the Community, CFMS CommunityCare may engage a trusted third party to provide clinical review and/or pre-negotiation services for procedures and treatments. A failure to notify CFMS CommunityCare before your scheduled health event, which prevents CFMS CommunityCare from performing appropriate due diligence and fair price comparison, may impact your Health Cost Score or eligibility for funding.

Emergency & Urgent Care

For all unplanned urgent or emergency care, inform your Care Advocate as soon as possible about the health event, so we can guide you through your health journey and offer you the best Member support possible.

When receiving urgent or emergency care, state that you are a self-pay patient and ask to be billed after your care. CFMS CommunityCare can facilitate negotiation on your behalf for emergency room bills before you pay them. 

Prescriptions

For your prescriptions to be eligible for crowdfunding, you must use your prescription discount when purchasing and choose a generic option if available. You will show your RX discount card (accessible through your Member profile in the app) at the pharmacy to get the best price, pay at checkout, and submit the prescription receipt through the app for crowdfunding.

Maintenance prescription drug costs eligible for crowdfunding are generally limited to a 120-day supply per valid health event.

Children’s Immunizations

For all children’s immunizations, you must use a Vaccines For Children (VFC) provider for any related expenses to be eligible for funding as part of the valid health event. Learn more under “Caring for Your Family,” below.

How It All Comes Together

To help you get a clearer idea of the Member experience, below is an example to walk you through the process.

A family of four (two parents in their thirties, a toddler, and an elementary schooler) pays $55 per person each month for cash-pay resources and advocacy support. This month, their crowdfunding requests totaled $322 ($420 maximum), meaning they’re spending $542 as a part of the Community and saving over $900 compared to the $1500 in health insurance premiums they were paying before (in addition to satisfying large deductibles before their coverage kicked in, plus ongoing copays and expensive coinsurance—yuck!).

Here’s what navigating a health event looks like for these Members:

The family ventures out for a hike one Saturday morning, and Dad takes a bad fall and hurts his knee. He’s in a good bit of pain, but it’s not an emergency, and it’s the weekend. Conveniently, he opens the CFMS CommunityCare app, logs a new health event, and requests a virtual urgent care appointment. The virtual doctor is available fast and, between a video evaluation and listening to Dad describe his symptoms, diagnoses a sprain.

The doctor writes a prescription for pain medication, so Dad goes to his neighborhood pharmacy and uses the CFMS CommunityCare prescription discount tool to get a great price. He shows his digital RX card and pays for the prescription at checkout. The virtual doc also recommends a follow-up appointment in person, so Dad contacts his Care Advocate, who helps him find a high-quality, fairly priced orthopedist in his area. When Dad arrives at his appointment, he lets them know he's a self-pay patient (inquires about a self-pay discount) and pays for his visit at checkout.

Dad’s knee is starting to feel better as the swelling goes down, but the orthopedist says he’ll need a few sessions of physical therapy to be back to 100%. Dad gets a referral from his doctor for a highly-regarded PT and calls the office to ask for a cash pay estimate before he schedules. He sends the pricing to the Care Advocate, who confirms it’s a reasonable price for his care, then schedules the appointments he needs.

Four weeks later, he’s done with PT, and his knee is feeling great. He has scanned in the receipts for his prescription, orthopedist visits, and physical therapy sessions in the CFMS CommunityCare app. His bills totaled $725 for the health event, so $225 (the event-related expenses beyond his initial $500 Member Commitment) is submitted for crowdfunding. Through the easy-to-use CFMS CommunityCare platform, with support from the Care Advocate, and thanks to the generous Member Community, Dad got the quality care he needed right when he needed it.