By Texas Medical Association
As originally published in Mega Doctor News newsprint edition August 2018
As the health care market changes, doctors warn that what some patients believe to be alternative forms of health insurance, could leave them with unpaid medical bills or without health coverage when they really need it. One increasingly popular alternative āa health care-sharing ministryāallows members with similar beliefs to share each otherās health care costs.Ā
These ministry members typically pay a monthly share, which is intended to cover the health care costs of other members. Members also are responsible for paying their own deductible, which is the amount of individual medical costs they must pay before others share their subsequent costs. Health insurance operates similarly. However, health care sharing ministries are not insurance companies, so they are not subject to Texas Department of Insurance (TDI) regulation. For example, some ministry programs will not cover enrolleesā preexisting health conditions. The Texas Medical Association (TMA) is receiving more calls about these entities and is keeping a careful eye on ministriesā coverage and physician payment issues reports the August issue of Texas Medicine Magazine.
āItās one thing to say youāre going to have lower premiums and deductibles,ā Austin internist Tony Aventa, MD, a member of TMAās Council on Socioeconomics, said.
āBut then again, if youāre going to be surprised on the back end, I donāt know if that necessarily is a good solution.ā Dr. Aventaand other physicians say health care sharing ministry members who do not understand their health care coverage could face medical claim denials, insurance audits, and a long-appeals process if some medical procedures are not covered. That is because health care sharing ministries do not possess the same consumer protections health insurance plans are required to contain.
Earlier this year, The Texas Medical Association wrote to the Texas Department of Insurance expressing concerns from physicians about sharing ministriesā coverage denials. TMA also noted that some ministry plans promote their use of preferred provider organizations (PPOs) or networks ā language used by health insurers. āThis language is very misleading to both physicians and individuals purchasing these plans,ā TMA told TDI. āThe term āPPOā is associated with medical insurance coverage.ā
TMA asked TDI to inform consumers that health care sharing ministries are not insurance. TMA also sought a response about ministriesā promoting themselves using PPO language. TDI responded that it would review TMAās recommendation.
Doctors cite concerns over ministries denying patientsā coverage. In one case, Dallas otolaryngologist Evan Bates, MD, noticed a health care sharing ministry denied a patientās ear-tube surgery, blaming a preexisting condition.
āThey looked back at the history, and they were basically telling us that if the child had ever had an ear infection prior to being covered under this program, that they were denying the procedure as being due to a preexisting condition,ā Dr. Bates said. (Many children experience ear infections at some point in their lives.) The patientās parents appealed, and the ministry ultimately reversed its decision.
In other cases, some physicians say their patients are satisfied with their health care sharing ministry coverage, in spite of some limitations. Fort Worth internist and sharing ministry customer Steven L. Smith, MD, runs a direct primary care medical practice. Dr. Smith says he collects patient payments upfront and gives them an invoice to submit to their sharing ministry for partial reimbursement of his fee.
The ministries are āa huge benefit in the face of these high-deductible, no-coverage, hopefully, quasi-catastrophic plans,ā Dr. Smith said, especially with anticipated changes to the Affordable Care Act (ACA) insurance plans. āAnd 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, itās awesome.ā
Meanwhile, patients and busy physician practices are on their own to learn how health care sharing ministry coverage differs from traditional health plan coverage. āItās just a company that says, āWeāre not an insurance company, so we donāt have to abide by the same rules that the insurance companies abide by.ā But from a physician or providerās standpoint, and certainly from a patient standpoint, theyāre behaving like an insurance carrier by any other name,ā Dr. Bates said. āThatās where I think the confusion comes in on both sides of the equation. Weāre hoping for better transparency to help physicians and patients understand how health coverage is different in these programs.ā