Healthshare vs Insurance

Amarante

Thu, Jan 02 2020, 4:54 pm

A timely article from today's New York Times

https://www.nytimes.com/2020/0.....epage

It Looks Like Health Insurance, but It’s Not. ‘Just Trust God,’ Buyers Are Told.

By Reed AbelsonUpdated 3:48 p.m. ET
Some state regulators are scrutinizing nonprofit Christian cost-sharing ministries that enroll Americans struggling to pay for medical care, but aren’t legally bound to cover their members’ claims.

Mark Collie and his son Blake at home in Washington, N.C. When Blake suffered an aneurysm, Mr. Collie turned to a Christian health cost-sharing ministry to help cover the costs.Madeline Gray for The New York Times
Eight-year-old Blake Collie was at the swimming pool when he got a frightening headache. His parents rushed him to the emergency room only to learn he had a brain aneurysm. Blake spent nearly two months in the hospital.
His family did not have traditional health insurance. “We could not afford it,” said his father, Mark Collie, a freelance photographer in Washington, N.C.
Instead, they pay about $530 a month through a Christian health care sharing organization to pay members’ medical bills. But the group capped payments for members at $250,000, almost certainly far less than the final tally of Blake’s mounting medical bills.
“Just trust God,” the nonprofit group, Samaritan Ministries, in Peoria, Ill., said in a statement about its coverage, and advises its members that “there is no coverage, no guarantee of payment.”
More than one million Americans, struggling to cope with the rising cost of health insurance, have joined such groups, attracted by prices that are far lower than the premiums for policies that must meet strict requirements, like guaranteed coverage for pre-existing conditions, established by the Affordable Care Act. The groups say they permit people of a common religious or ethical belief to share medical costs, and many were grandfathered in under the federal health care law mainly through a religious exemption.
These Christian nonprofit groups offer far lower rates because they are not classified as insurance and are under no legal obligation to pay medical claims. They generally decline to cover people with pre-existing illnesses. They can set limits on how much their members will pay, and they can legally refuse to cover treatments for specialties like mental health.
“Nothing is guaranteed,” said Dr. Carolyn McClanahan, a physician who is also a financial planner in Jacksonville, Fla. “You have to depend on the largess of the program.”
The main requirement for membership is adherence to a Christian lifestyle. And the alternative sharing plans keep flourishing, especially now that the Trump administration has relaxed rules to permit alternatives to the A.C.A. that don’t provide such generous coverage.
But state regulators in New Hampshire, Colorado and Texas are beginning to question some of the ministries’ aggressive marketing tactics, often using call centers, and said in some cases people who joined them were misled or did not understand how little coverage they would receive if they or a family member had a catastrophic illness.

On Monday, Washington State fined one of the larger health-sharing ministries, Trinity Healthshare, $150,000 and banned it from offering its product to state residents because it was operating as an unauthorized insurer.

In December, Nevada insurance regulators warned consumers to beware of these plans. “They may seem enticing because they may be cheap, look and sound like they are in compliance with the Affordable Care Act (‘A.C.A.’), when in reality these plans are not even insurance products,” the department said.
The Texas attorney general brought a lawsuit last summer against Aliera Healthcare, which marketed Trinity’s ministry program, to stop it from offering “unregulated insurance products to the public.” The Houston Chronicle featured one couple who was left with more than $100,000 in unpaid medical bills. Trinity said most members are satisfied with its services.

Aliera, which says it has stopped offering its plans in Texas, said it is working with regulators to resolve their concerns. The company says it has taken steps to make sure its customers are not confused about what they are buying.

Because the groups are not technically considered insurance, they operate with no government oversight. “Regulators haven’t been willing to assert any control or regulatory authority over these plans,” said Katie Keith, who serves as a consumer representative to the National Association of Insurance Commissioners and teaches health law at Georgetown University. “They feel their hands are tied. At the end of the day, it’s not insurance.”

Families who have joined the groups recount winding up with medical bills not covered by the ministries, with no legal way to appeal decisions to reject coverage for care. Some groups ask their members to push hospitals and doctors to write off their bills rather than use members’ money to pay their expenses.
“These plans offer a false sense of security,” said Jenny Chumbley Hogue, who runs an insurance agency in the north Dallas area of Texas. She refuses to offer them to her clients.

Several states have taken action against one ministry they say has deceived people about what they are buying. “The nature of what we’re hearing from consumers around the state is absolutely heart breaking,” said Kate Harris, chief deputy insurance commissioner in Colorado, one of the states that is trying to prevent the ministry from operating there.

But health-share ministries have become particularly attractive to people like the Collie family who don’t qualify for a federal subsidy and can’t afford an A.C.A. plan. Even though premiums in the A.C.A. market have stabilized, critics of the law insist people need alternatives. “That’s the real driver behind the growth,” said Dr. Dave Weldon, a former Republican congressman from Florida who is president of the Alliance of Health Care Sharing Ministries, which represents the two largest groups.
When Dan Plato left his job to become self-employed as a consultant, he discovered that an A.C.A. policy for 2018 would cost his family around $1,300 a month. “It was very expensive and beyond our needs,” he said. Membership in Liberty Healthshare, a ministry established by Mennonites in Canton, Ohio, was less than half the price, according to Mr. Plato, who blogged about his experience.

But some Liberty members reported trouble getting their medical bills covered. Mr. Plato says a small bill for flu shots went unpaid and ended up in collection. At the end of the year, he was left wondering if Liberty would be able to cover the family in the event of a serious medical emergency. “It’s not something we could trust in that situation,” said Mr. Plato, who switched to one of the plans offered by United Healthcare also exempt from the A.C.A. rules for 2019.

Robyn Lytle, who works as an event planner in Chicago, joined Liberty for 2018, only to find that her daughter’s medical tests were never paid. “It’s been a year and a half, and I’ve been sent to collection,” said Ms. Lytle, who says Liberty had covered some of her family’s other expenses. She switched to an A.C.A. plan for 2019.
Liberty Healthshare declined to comment.

Other people complain that the ministries can be vague about coverage. Greg Snider and his wife joined Medi-Share, the program offered by Christian Care Ministry. Based in West Melbourne, Fla., Medi-Share says it has more than 400,000 members across the country.

Mr. Snider said he had just dropped traditional coverage when his wife was diagnosed with a heart condition, but he says he was assured by Medi-Share that her care could still be covered. She underwent surgery last year to address an abnormal heart rhythm. “After the procedure, the bills start rolling in,” Mr. Snider said, including $177,000 for the surgery alone.

Mr. Snider says Medi-Share urged him to plead with the hospital after determining he would owe more than $100,000. He said he had assumed the $800 a month he paid into a pool would help cover the expenses. After he tweeted his frustrations, the ministry told him that he would owe only $1,500 for the surgery because the hospital had forgiven the rest, he said. He now owes thousands of dollars in related medical bills and is unsure of their status.

If Medi-Share decides not to pay, Mr. Snider knows he has little recourse: “It is completely and solely up to them.” He has since gotten a job where he is covered under his employer.

Medi-Share says that more than 80 percent of the $774 million it collected last year went to members’ medical bills. “We take great care to ensure prospective members understand what is considered a pre-existing condition and what is eligible for sharing,” it said.

It does its part to reduce medical spending, it says, through negotiating with doctors and hospitals and claims it saved members more than $500 million last year. “We consider this process to be one way in which we contribute to the overall objective of reducing medical costs,” the ministry said in a statement.
Medi-Share says it has an extensive network of more than 700,000 providers. But even if a member goes to an in-network provider, the ministry may still decide not to pay the bill. “Fundamentally, we have found that there is often a lack of understanding of what is covered,” said Brendan Miller, an executive with MultiPlan, which arranges networks for Medi-Share as well as insurers.

That uncertainty has led some hospitals and doctors in the MultiPlan network to refuse to treat ministry patients rather than absorb unpaid costs.

Colorado is one of several states, including Washington, Texas and New Hampshire, that are trying to stop Trinity Healthshare, and its administrator, Aliera Healthcare, from operating in their states because they say the ministry is misleading its residents.

In a statement, Aliera said “it’s deeply disappointing to see state regulators working to deny their residents access to more affordable alternatives offered by health care sharing ministries.”

Trinity says its website makes clear that the ministry does not offer health insurance.

Regulators also worry about these plans siphoning off healthy individuals from the A.C.A. marketplaces, leading to higher premiums for Obamacare policies.
“The ministries have been very concerned about bad actors invading this space,” said Dr. Weldon, the alliance president, who says his members are very clear that they are not insurance companies. “They all operate call centers, and they all bend over backward to inform people inquiring that it is not insurance,” he said.
In the case of Samaritan, which says it covers 271,000 people, the ministry pointed to its Save to Share program, where members can contribute extra to cover more of their bills.

With Blake’s bills likely to far exceed the cap — Mr. Collie has not yet tallied them — he created a GoFundMe account to help pay for his son’s care.

Mr. Collie says the ministry remains a viable alternative, noting it paid for numerous medical bills before his son’s hospitalization. “Every single person has prayed for me and my family,” he said. But he was enormously relieved when he found out recently his son qualified for Medicaid, the state-federal insurance program, which will cover the boy’s full medical care.

In some states, officials are starting to consider requiring the groups to register, to obtain more information for consumers.
Peter V. Lee, a former Obama administration official who now runs the California A.C.A. marketplace, said ministries should be subject to some oversight, including disclosure of how much of the money collected is spent on care.

“There should not be a religious exemption for transparency — where the money goes and if it will be there if consumers need it,” he said.
California is also requiring brokers, who are paid hefty commissions by some of the ministries to enroll members, to make sure their clients understand they are not buying insurance.

Some ministries, like Samaritan, say they do not use brokers or agents. “We also have never, nor will we ever, use insurance agents or brokers to sell Samaritan because we don’t want people to confuse us with insurance,” it said.

Amarante

Thu, Jan 02 2020, 4:56 pm

And an article referenced in the NY Times article

https://www.houstonchronicle.c.....8.php

DALLAS — When David Martinez switched jobs, he was suddenly without health insurance for the first time in his life. For months, the businessman searched for an affordable plan until a broker steered him to a Georgia company promising comprehensive coverage for about one-third of the cost of other plans.

What Aliera Healthcare was peddling was not insurance, but rather connection to a Christian health care cost-sharing ministry, an obscure but growing type of coverage based on the biblical principle that the like-minded should help each other in times of need. Members contribute monthly into an Aliera-administered fund to help pay their future medical bills.

It sure sounded like insurance to Martinez. Or close enough. And, as a Christian, he figured any company marketing faith should be more trustworthy. He signed up in April 2018 and began paying Aliera thousands of dollars. The only problem: The plan turned out to be worthless. He now owes $129,000 in medical bills currently in collections.

As similar cases have surfaced across the country, regulators in several states, including Texas, are taking action against Aliera, accusing the 4-year-old company of fraudulently selling insurance without a license — a charge Aliera denies. But the story runs deeper, emerging as a tangled tale of broken deals, politics, religion, prison and, of course, money. And it is unfolding at a time when the nation’s health insurance regulations are steadily unspooling.

Martinez became ensnared when his wife underwent urgent surgery and Aliera refused to pay, denying the claim multiple times and asserting that Megan Martinez had a pre-existing condition, even though her doctor said she did not. Further, since Aliera is not technically insurance, it is not bound by laws that would require coverage under the Affordable Care Act, nor does it fall under much other oversight.

“It really is an extraordinary case,” said Jo Ann Volk, a research professor at the Georgetown University Center on Health Insurance Reforms, who has been watching from afar. “There are completely legitimate health-sharing ministries out there, but there are others that are taking advantage of this wild west of insurance we are living in now.”

A request for comment from Aliera was forwarded to a public relations spokesman who answered questions and issued a company statement by email. Aliera’s leadership was not available for interviews. Attempts to reach them directly were unsuccessful. Details for this story were taken from court records in Texas and Georgia, as well as interviews with regulatory officials and former Aliera members.

“We will vigorously defend against the false claims directed at our company,” Aliera said in the statement, “and we are confident we will prevail when these questions are ultimately determined by impartial judicial review.”

On Tuesday, the day this story appeared online, an Aliera claims director called Martinez and said the company had reversed its previous denials and would pay the entire claim.

20 cents on the dollar

On May 7, the Texas Department of Insurance said it would seek a cease and desist order in administrative court against Aliera for misleading customers into thinking they were buying insurance and blurring the line between the for-profit parent company and its affiliated nonprofit health-share ministry. The company countered members know exactly what they are getting.

Still, the similarities between traditional health insurance plans and the products Aliera promotes can be striking. Aliera’s website touts individual and family coverage that includes “primary care physician visits, pharmaceuticals, basic eye and hearing examines (sic), both in- and out-patient procedures, extended hospitalizations, urgent care needs, labs and diagnostic procedures.” Plans come in gold, silver and bronze, using the same metal designations as insurance plans offered under the Affordable Care Act’s exchange.

On HoustonChronicle.com: It costs what? Medical pricing shrouded in secrecy

Aliera, however, is under no legal obligation to pay claims. In fact, authorities allege just 20 cents out of every dollar collected in member fees appear to go to medical bills. That’s the exact opposite of Affordable Care Act rules that generally require insurers devote 80 percent of what they collect in premiums to covering health care costs.

Texas insurance authorities also say that Aliera’s affiliated health-sharing ministry, Trinity HealthShare, fails to comply with state rules on such groups and operates as a “shell that was created to disguise Aliera and its control by Aliera.”

In a Texas court filing, Aliera denied “each and every, all and singular, material allegations.”

Aliera has more than 100,000 overall customers nationwide, with 17,000 in Texas, and its annual revenue last year was $215 million, the company said.

It also confirmed it pays Texas insurance brokers up to 30 percent commission to enroll members, with an average of about 15 percent. The typical commission for selling a health plan in the state is between 2 and 5 percent, according to several Texas brokers.

Six days after Texas’ action, Washington ordered Aliera to stop doing business in that state, alleging “deceptive business practices.” The next day, on May 14, New Hampshire issued a warning about Aliera on its website. And by month’s end, Colorado’s insurance commissioner posted a broad caution against health care-sharing ministries: “If it sounds too good to be true, it probably is.”

Then, on June 13, Texas Attorney General Ken Paxton sued Aliera in state district court, mostly mirroring the Texas Department of Insurance complaint, but seeking penalties of $10,000 for each violation and for each day of violation. No hearing date has been set.

Aliera has vowed to fight back in both Texas and Washington.

Family affair

Aliera Healthcare Inc. was formed at the end of 2015 as a for-profit corporation with headquarters in Atlanta, incorporation records in Delaware show. The CEO is Shelley Steele and her son, Chase Moses, is president. Her husband, Timothy Moses, was executive director until April when he left to become business development specialist at Ciel Capital Group, described as a privately held Atlanta consulting firm.

In October 2005, Timothy Moses was convicted in Atlanta of two counts of federal securities fraud and one count of perjury. Then the CEO of a bankrupt biotechnology firm, he was found guilty of artificially inflating the value of his company’s stock through news releases and selling his shares right before the price crashed, according to the U.S. Securities and Exchange Commission and the U.S. Attorney’s Office for the Northern District of Georgia.

On HoustonChronicle.com: A Texas woman’s fight with a health care system she say let her down

He was sentenced to 78 months in prison and ordered to pay more than $1.6 million in restitution. He also was ordered to five years of supervised probation beginning in early 2011. But federal prosecutors later tried to send him back to prison for allegedly violating the terms of his probation, including failing to make restitution payments, opening new lines of credit and not being truthful about his finances to his probation officer, according to court documents. His attorney disputed the allegations and Moses avoided a return to prison because of health issues, court papers show.

Attempts to reach Moses for comment were unsuccessful.

In April 2015, Moses’ probation ended. Eight months later, he and his wife launched Aliera and began marketing what the company called “insurance alternatives.”

Soon after, Aliera joined forces with a small Virginia health-sharing ministry called Anabaptist Healthcare, run by Mennonites. The deal was supposed to expand the reach of both Anabaptist and Aliera. A new ministry, Unity Healthshare, was formed with Aliera in control of nearly all operations.

It wasn’t long, though, before the partnership went south, ending in a nasty court fight still playing out in Georgia.

Aliera filed a lawsuit last August, contending breach of contract and claiming it had built Unity into a successful company, but the leadership of Anabaptist “executed a scheme to cripple Aliera’s entire business” by stealing intellectual property and freezing assets, according to the litigation.

Anabaptist countered that Aliera had been deceptive and misused Unity membership funds — which were to remain separate from Aliera’s — for its own purposes, including $150,000 in checks that Moses wrote to himself. Aliera has said it was a misunderstanding and the money was paid back.

By the time Aliera parted ways with Anabaptist, it had already formed a new health share ministry, called Trinity Healthshare Inc., populating it with Aliera employees and automatically moving Unity members to Trinity unless they specifically opted out. In April, the Georgia judge issued an injunction against Aliera to stop the transfer of money and members pending the outcome of the case. Aliera appealed the order.

Big business

The concept of health care cost-sharing ministries is often likened to an old-time Amish barn-raising, with people of faith helping each other in times of trouble. But in fact, the groups have become big business and increasingly under scrutiny.

Because they are mostly unregulated, no one knows for sure how many exist in this country, where they are or how many members they have. A decade ago, overall membership in health-share ministries was thought to be around 200,000. Now, it is estimated at more than 1 million.

Health policy experts believe what propelled the rapid growth is a special carve out in the Affordable Care Act that exempted members from the law’s requirement to carry traditional health insurance or face a penalty. Lawmakers agreed to the exemption after the groups argued it was a matter of religious freedom.

Then, as premiums for individual plans offered through the ACA began to rise sharply, so, too, did interest in the typically cheaper offerings from health-sharing ministries, especially among those who had lost traditional coverage. And as membership grew, the marketing became louder and more sophisticated. Some began relaxing requirements to join.

Health policy advocates and regulatory authorities worry customers may not fully realize they are not buying insurance and there is no guarantee of coverage — or much recourse if something goes wrong. Aliera, for example, avoids traditional insurance terminology to sell its plans, but has used other words for the same concepts. In a broker’s email to another Aliera customer, obtained by the Chronicle, a translation was offered: “Member Shared Responsibility Amount = Deduction” and “Consult Fee = Co-Pay.”

Texas authorities accuse Aliera of piggybacking on the health-sharing ministry concept, cashing in on the religious appeal and limited regulations. Aliera argues it offers health-share plans as just one option from a larger menu, calling them “a choice government at all levels should respect.”

The Price You Pay: Murky health care business practices trap patients at their most vulnerable

In Texas, a health-sharing ministry must be bound by people of a similar faith. The Trinity Healthshare bylaws do not specify any particular religion. When members enroll they are required to sign a series of belief statements that include “personal rights and liberties originate from God and are bestowed on us by God” and “every individual has a fundamental religious right to worship God in his or her own way.”

Martinez, the Dallas businessman, thought the belief statements were just a formality. What hooked him was the price. Coverage for him and his wife was about $680 per month, compared with $1,800 for a plan through the ACA.

His annual Membership Shared Responsibility Amount was $5,000. After it was paid, he said he was told they would have 100 percent coverage. In many traditional insurance plans, members are still responsible for a portion of their medical costs even after their deductible is met.

In June 2018, Megan Martinez underwent surgery for diverticulitis. Aliera had pre-approved the procedure and the couple paid their $5,000, assuming there would be no further bills, Martinez said. And initially it appeared Aliera would indeed pay nearly all of the $130,000 in billed charges, according to the couple’s estimate of benefits.

But then overdue notices began rolling in.

When Martinez confronted Aliera, the company said his wife’s surgery sprang from a pre-existing condition so it was not covered after all. Even when her doctor told the company it was not pre-existing, Aliera would not budge, he said.

“What are you saying, the doctor’s a liar?” Martinez argued.

“We sympathize with them and their frustration, as this is an unfortunate example of the need to understand health plan details, especially what is eligible for cost sharing and what is not — such as a pre-existing condition in this case,” Aliera said in a statement about the Martinez case.

But on Tuesday a claims director called Martinez and said the previous denials were reversed and the claim would be paid.

In a corresponding letter, Aliera said the claim had initially been denied because of his wife’s pre-existing condition and because robotics were used in the surgery, which was not authorized. But the company said that upon further review it was “not definitive” there was a pre-existing condition and that robotics use had become prevalent enough in surgeries that coverage would be allowed.

“It’s very good news,” Martinez said after the call, “but it’s not good news until all the doctors and the hospitals get paid. I am still very skeptical about all of this. We never should have been put in this position.”

In February he had joined scores of other unhappy customers across the country by venting on Yelp: “Do not be fooled by these so-called faith-based healthcare companies as they do not practice the golden rule at all.”

The company responded online: “Thanks for bringing this to our attention. We’re sorry to hear you didn’t receive the reimbursement you expected.”

Little did Martinez know, the Texas Department of Insurance was scouring online reviews as it built its case against Aliera. He was contacted by TDI lawyers and added to a potential witness list. In April he stopped paying his Aliera member fees. He has now hired a lawyer and bought a UnitedHealthcare plan.

“I’m angry. And I’m embarrassed,” he said, “but mostly I’m disgusted by the hypocrisy. They are no more faith-based than Satan himself.”

Last edited by Amarante on Thu, Jan 02 2020, 5:05 pm; edited 1 time in total