One increasingly popular alternative — a health care-sharing ministry — has presented a mixed bag of experiences for Texas physicians. Health-care-sharing ministries (HCSMs) are organizations in which members who adhere to similar beliefs share each other’s health care costs.
The monthly cost for a patient or family in a ministry plan is usually cheap relative to a monthly insurance premium. However, neither the Affordable Care Act nor the Texas Department of Insurance (TDI) consider ministries to be practicing insurance, so they’re not regulated in the same way as traditional health plans.
Dallas otolaryngologist Evan Bates, MD, has noticed the difference in the past year after some initial coverage denials from a national HCSM, Christian Care Ministry. One was for an ear-tube surgery. The reason: It was treatment for a pre-existing condition.
“They looked back at the history, and they were basically telling us that if the child had ever had an ear infection prior to them being covered under this program, that they were denying the procedure as being due to a pre-existing condition,” Dr. Bates said.
The patient’s parents appealed and the ministry reversed its decision. But coverage for a tonsillectomy Dr. Bates’ performed was still up in the air at press time also because it was considered to be treatment for a pre-existing condition.
With potential coverage and physician payment issues arising from HCSMs, the Texas Medical Association is keeping a careful eye on how the ministries operate in Texas. Earlier this year, after receiving a number of calls from physicians, TMA wrote to TDI expressing concern about the ministries’ public representation of their products.
“It’s just a company that says, ‘We’re not an insurance company, so we don’t have to abide by the same rules that the insurance companies abide by.’ But from a provider’s standpoint, and certainly from a patient standpoint, they’re behaving like an insurance carrier by any other name,” Dr. Bates said. “That’s where I think the confusion comes in on both sides of the equation. We’re hoping for better transparency to help providers and patients understand how health coverage is different in these programs.”
But HCSMs have their fans among physicians frustrated with traditional health plan hassles.
Fort Worth emergency physician Jeffrey Erdner, DO, has contracted with Florida-based Christian Care Ministry for about a year.
“From an administrative side, my experience has been they pay their bills, and honestly, they’re friendly to talk to in all of my dealings with them. … We don’t get ridiculous denials like we do from … private insurances every day,” he said.
How it works
Here’s an example of how HCSM’s typically work: Christian Care Ministry is also known by its sharing program’s name, Medi-Share. It uses two key amounts for each member individual or household: An annual household portion and a monthly sharing amount.
The annual household portion, similar to a deductible, is the amount of medical costs the member is responsible for before others share that person’s subsequent costs. Michael Gardner, senior director of communications for Christian Care Ministry, says members can tailor their annual household portion depending on their family’s needs. Mr. Gardner’s family of four, for instance, is responsible for the first $10,000 of their medical needs.
The monthly share is a fixed amount the member deposits each month for the medical needs of other ministry members. The monthly sharing amount depends on the size of the member’s household, the age of the household’s oldest person, and the annual household portion.
According to the membership requirements on Christian Care Ministry’s website, Medi-Share members must abide by a “healthy lifestyle” and not have used tobacco or illegal drugs, or abused legal drugs, for at least 12 months prior to applying for membership. They also must abstain from sex outside of marriage.
“A lot of our members really value the fact that they don’t pay for things that they may morally object to,” Mr. Gardner said. “And it’s there to lift burdens as well. They’re paying so that other members are going to come alongside them for burdens. It’s not really intended to cover every single need.”
HCSMs like Christian Care Ministry and Liberty HealthShare state on their websites that their programs aren’t insurance. Their membership cards are required to say the same. And there are key differences in what they will cover.
Ministries typically restrict coverage of pre-existing conditions. For example, Medi-Share only begins covering the cost of a pre-existing condition once the member has been sharing for 36 months, or if the person’s medical records show the condition has gone 36 months without signs or symptoms, treatment, or medication. Also, Medi-Share doesn’t cover the cost of preventive care, explaining on its website that its primary purpose is to share members’ “burdens,” which it defines as “unexpected medical bills you are unable to plan for.”
Medi-Share operates in all 50 states with more than 400,000 members nationwide and 62,000 in Texas. Some states previously shut down Medi-Share: Following a lawsuit against it, a Montana district court ruling outlawed the program there beginning in 2007. A new insurance commissioner readmitted Medi-Share to Montana in 2017.
Mr. Gardner says the underlying cause of those “situations in other states” stems from misunderstandings of what kind of care is and isn’t eligible for sharing.
“There’s a misconception that sharing ministries kind of operate with vague descriptions, and in our case, that’s not true,” he said. “We do have printed, written member guidelines that clearly explain what is eligible for sharing, ineligible for sharing, or has limitations on sharing.”
Confusion surrounding HCSMs and their potential proliferation put TMA on alert.
The ACA exempted certain HCSM members from the law’s individual mandate and tax penalty for not carrying minimum essential coverage. With that mandate disappearing in 2019, alternatives to health insurance may become even more popular.
Because the ministries aren’t considered insurance providers, TDI has no regulatory authority over them. TMA approached TDI in March 2018, recommending the agency issue a post on its website to inform consumers HCSMs aren’t offering insurance. TMA was particularly concerned about Medi-Share promoting its use of the Private HealthCare Systems preferred provider organization (PPO) network.
“This language is very misleading to both physicians and individuals purchasing these plans,” TMA told TDI. “The term PPO is associated with medical insurance coverage.”
TDI responded that it would review TMA’s recommendation.
Meanwhile, patients and busy physician practices are on their own to discern upfront how ministries’ coverage differs from health plans.
Genevieve Davis, TMA’s associate vice president of payment advocacy, says whoever is usually responsible for taking the patient’s insurance card should check closely to see if the patient is handing over a ministry membership card. Texas law states that if a ministry distributes a membership card, the card must clearly indicate the ministry is not an insurance company.
After identifying a ministry card, practices can make a business decision about whether to accept assignment or ask patients to pay in full and seek reimbursement on their own.
After denials, audits, and appeal letters for a couple of procedures, Medi-Share finally “came back and paid,” said Dr. Bates’ office manager, Madison Brewer.
“You don’t like doing procedures and … having parents out on a limb if a procedure doesn’t get covered, because then they’ve got issues with the facility as well,” Dr. Bates said. “And some of the facilities don’t accept this plan.”
Austin internist Tony Aventa, MD, a member of TMA’s Council on Socioeconomics, also experienced challenges with coverage denials from ministry plans.
“It’s one thing to say you’re going to have lower premiums and deductibles,” he said. “But then again, if you’re going to be surprised on the back end, I don’t know if that necessarily is a good solution.”
Some doctors, even as patients, are grateful to not be dealing with traditional health plans.
Conroe emergency physician Donald C. Frame, MD, a customer of Liberty HealthShare, says despite limitations, particularly with prescriptions, “it’s been a great deal for us.” He doesn’t view the lack of oversight as much of a disadvantage since taking a health plan to court can be a costly proposition anyway.
Also a Liberty customer, Fort Worth internist Steven L. Smith, MD, who runs a direct primary care practice, says his family pays $320 for its monthly share amount. For his Liberty patients, he collects their payment and gives them an invoice that they can submit to Liberty for partial reimbursement of his fee.
Ministries are “a huge benefit in the face of these high-deductible, no-coverage, hopefully quasi-catastrophic plans,” he said. “And with the coming year and the dissolution of all these regulations that have been associated with ACA, there may be other alternatives that are equally as affordable. But I think that as an affordable means to coverage, it’s awesome.”
Read more at Sharing is Caring?