Health Care Sharing Ministries Are Not Typical Health Insurance Doctors Caution

Texas Medical Association (TMA) Texas Insider Report: AUSTIN Texas  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 a health care-sharing ministry allows members with similar beliefs to share each others health care costs. 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 enrollees preexisting health conditions. The Texas Medical Association (TMA) is receiving more calls about these entities and is keeping a careful eye on ministries coverage and physician payment issues reports the August issue of Texas Medicine magazine. Its one thing to say youre going to have lower premiums and deductibles" Austin internist Tony Aventa MD a member of TMAs Council on Socioeconomics said. But then again if youre going to be surprised on the back end I dont know if that necessarily is a good solution." Dr. Aventa and 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 TMA wrote to TDI expressing concerns from physicians about sharing ministries coverage denials. TMA also noted that some ministry plans promote their use of preferred provider organizations (PPOs) or networks language used by health insurers. 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." TMA asked TDI to inform consumers that health care sharing ministries are not insurance. TMA also sought a response about ministries promoting themselves using PPO language. TDI responded that it would review TMAs recommendation. Doctors cite concerns over ministries denying patients coverage. In one case Dallas otolaryngologist Evan Bates MD noticed a health care sharing ministry denied a patients ear-tube surgery blaming a preexisting 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 being covered under this program that they were denying the procedure as being due to a preexisting condition" Dr. Bates said. (Many children experience ear infections at some point in their lives.) The patients 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 a huge benefit in the face of these high-deductible no-coverage hopefully quasi-catastrophic plans" Dr. Smith said especially with anticipated changes to the Affordable Care Act (ACA) insurance plans. 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 its awesome." The elimination of the ACAs individual mandate tax penalty beginning in 2019 could make alternatives to traditional health coverage more popular. Meanwhile patients and busy physician practices are on their own to learn how health care sharing ministry coverage differs from traditional health plan coverage. Its just a company that says Were not an insurance company so we dont have to abide by the same rules that the insurance companies abide by. But from a physician or providers standpoint and certainly from a patient standpoint theyre behaving like an insurance carrier by any other name" Dr. Bates said. Thats where I think the confusion comes in on both sides of the equation. Were hoping for better transparency to help physicians and patients understand how health coverage is different in these programs." TMA is the largest state medical society in the nation representing more than 51000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMAs key objective since 1853 is to improve the health of all Texans.