As health insurance premiums and deductibles on the state and federal health exchanges continue to rise each year, many people are seeking out alternatives to traditional insurance options. Consequently, health share plans — such as Medishare and others — have seen a surge in popularity.
While people who participate in these programs believe that they’ll be covered in the event of an emergency, they should be aware that health share plans are not actually health insurance. In fact, they often provide very limited coverage for medical services. If you’re considering a health share plan, it’s essential to understand how they work. Even though these plans can cost half as much upfront, just one incident could result in financial devastation for you and your family.
What is a Health Share Plan?
A health share plan — sometimes also known as healthcare sharing ministries — is essentially a cooperative. In other words, it is a group of people who come together and agree to share each other’s medical expenses. Typically affiliated with religious organizations, a healthcare sharing plan must be set up as a 501(c)(3) non-profit by law. Importantly, you should be aware that because health share plans aren’t insurance, they don’t have to follow state and federal health insurance regulations.
Those who participate in a medical cost sharing plan or a faith-based health sharing program pay a monthly share fee, as well as an annual unshared amount. Until the unshared amount is met, the participant is not eligible for sharing — similar to traditional health insurance in which the patient must meet the deductible before insurance will kick in.
Some health share plans affiliate with networks of doctors. In these cases, whatever you get charged will be reduced to the discounted rates applicable to the network. If your healthcare share plan doesn’t use a network, you can see any doctor you choose. However, you could end up being responsible for out-of-network costs or even footing the entire bill if the plan won’t cover the services.
What Do Health Share Plans Cover?
Health share plans vary widely, and there is no standard set of rules that they must follow. Every health share cooperative can decide what costs will be covered, as well as what will be excluded. They typically don’t offer pre-review of procedure or billing codes — so there’s no way of knowing in advance what amount you’ll end up being responsible for or how much will be shared for your medical services. The cooperative will look at a claim once it’s been submitted and investigate it.
When you submit your claim to a health share plan or healthcare sharing ministries, the first thing the cooperative will do is to undertake a pre-existing conditions investigation. They will request all information from your doctors to determine whether they can avoid considering your claim for sharing. Although patients can’t be denied coverage on a health insurance plan under the Affordable Care Act for a pre-existing condition, health share plans can. They may look back as many as five years into your medical history to make this determination. Not only will the health share plan look for an actual diagnosis, but also, it may not cover medical costs if there are any symptoms in your chart that could be associated with a pre-existing condition.
Some of the exclusions are specifically carved out in the health share plan. For instance, smokers are usually excluded and treatment related to mental health, alcohol, drugs, or contraception is typically not covered. Wellness visits and screenings may also be excluded from the plan. Additionally, some faith-based health sharing plans require that you be a member of a particular religion and make a statement of faith in order to participate in the program.
Can You Appeal a Coverage Decision With a Health Share Plan?
If your healthcare share plan determined it won’t cover costs associated with your medical treatment, you may be able to appeal the decision — but expect a challenge. There are generally no experts or doctors involved in the appeals process for a health share plan as with traditional insurance companies. Rather than a health share plan appeal being considered from a medical point of view, it will be looked at from a lifestyle or faith perspective.
The documents you received when you signed up for the plan should provide information concerning appeals. However, in many situations, the cooperative may be unwilling to budge and invite you to take legal action against them. If the health share plan won’t work with you, it may be possible to negotiate savings directly with the provider.
How Systemedic Can Help With Your Health Share Plan Bill Dispute
If you incurred a substantial medical bill for treatment you thought would be covered by your health share plan, an experienced medical bill dispute advocate can help. Systemedic has been assisting patients with medical bill disputes for over three decades and knows how to negotiate even the most complicated medical bills efficiently and effectively.
Offering a fee-based service for those looking to dispute their medical bills, our medical bill dispute advocates are skilled in navigating the insurance maze and will not take “no” for an answer. To get started with resolving your medical bill dispute, contact us for a consultation.