By Sean P. Murphy
Globe Staff, Updated June 1, 2021, 3:43 p.m.
Betsy Hargreaves wanted to save a few bucks on health
insurance a couple of years ago so she switched to a religious-based plan.
For a while it worked, cutting her monthly premium by
hundreds of dollars.
Then, in March, she had double hip-replacement surgery to
relieve acute pain, followed by a four-day stay in the hospital and extensive
physical therapy.
The surgery was successful, but Hargreaves’s “insurer”
refused to cover any of the costs, saying her surgery was the result of a
preexisting condition. She was saddled with nearly $75,000 in medical bills.
They told her the day before the surgery that it would not
be covered, she said.
Hargreaves’s financial crisis is rooted in her decision to
opt out of a traditional health insurance plan, which she says she did without understanding
all the ramifications.
Under the Affordable Care Act, traditional health insurers
are prohibited from denying coverage to members due to a preexisting condition.
It was one of the biggest selling points of Obamacare.
But Hargreaves’s plan, OneShare Health, is not traditional
insurance. It is a nonprofit “health care sharing ministry,” and like all such
ministries, exempt from the ACA, and therefore not legally mandated to cover
preexisting conditions.
Some health care ministries have come under sharp criticism
from state regulators who say their aggressive marketing efforts have misled
some consumers into the false belief their coverage is the equivalent of
traditional insurance, only cheaper.
At the bottom of its website homepage, OneShare says it is
not an insurer. In an e-mail, a spokeswoman for the nonprofit told me it’s
different from a traditional insurer because it does not assume the risk of
medical expenses incurred by its members, does not promise to pay expenses, and
makes no guarantee of coverage.
Instead, it collects monthly “contributions” — the
equivalent of premiums paid to insurers — from members and coordinates the
payment of eligible medical expenses among members according to its own
established rules.
Still, the nonprofit shares some of the look and feel of an
insurer with its offerings of various coverage packages with names like
“Catastrophic,” “Classic,” and “Complete,“ each with a schedule of per-visit
payments (looking a lot like copayments) and different in- or out-of-network
rates. (Hargreaves has the “Complete” plan, which is the most comprehensive.)
Health care sharing ministry members have “a common set of
ethical or religious beliefs and share medical expenses in accordance with
those beliefs,” according to the exemption in the ACA. Many of them are aligned
with Christian ideals or principles.
The OneShare website displays biblical quotations, including
one about carrying “each other’s burdens.”
More than a million people nationally are enrolled in about
100 nonprofit organizations such as OneShare.
The spokeswoman for OneShare said it currently has about 180
members in Massachusetts. These ministries are not licensed by the Division of
Insurance because they are not insurers.
About a dozen states, including Massachusetts, have issued
warnings to consumers about joining a health care sharing ministry.
“Consumers should use caution when considering alternatives
to traditional insurance plans . . . such as health care sharing ministries,”
the state Division of Insurance says. “These plans, while legal, do not offer
the same consumer protections.”
The Health Connector, the state’s health care exchange,
similarly says health care sharing ministries “do not necessarily cover
expenses for the same kinds of services that health insurance covers.”
The Division of Insurance has received no complaints about
OneShare, but it is conducting an investigation of another health care sharing
ministry.
In 2020, the Health Connector added a regulation that now
effectively blocks brokers or agents from selling health care sharing ministry
plans in the state.
The OneShare spokeswoman said the company abides by the
agent/broker restriction, but that Massachusetts residents are still able to
enroll “if they approach us.”
“We understand there are bad actors out there, so we
recommend people do their research” before signing on with a plan, the OneShare
spokeswoman said.
Hargreaves, 58, of Chatham, a self-employed real estate
agent, said the religious aspect of the plan was not the primary reason she
chose it. She was shopping for savings.
Hargreaves said she had purchased traditional health
insurance through a broker since 2015, but began discussing alternatives a
couple years later when her premiums rose significantly. At the time, brokers
were free to sell sharing ministry plans, and Hargreaves signed on to one such
plan in March 2019 and switched to OneShare at the beginning of 2020.
Hargreaves said she understood OneShare’s limitation on
preexisting conditions when she joined, but she sharply disagrees with
OneShare’s classification of her condition as preexisting.
A longtime runner and tennis player, she began experiencing
pain in her hips about two years ago.
At her annual medical checkup in 2019, she mentioned the
pain to her primary care physician, who recorded it in his notes, but took no
diagnostic steps.
This past January, with the pain worsening, Hargreaves had a
full workup, including X-rays and an examination by an orthopedic surgeon. A
date for surgery was set for two months later.
Hargreaves assumed coverage would be routinely approved. Her
ailment was degenerative, attributable to aging, not a preexisting condition,
she said.
Hargreaves said she did not hear back from OneShare on her
request for preapproval of coverage until the day before her surgery on March
4. She said she was shocked by the denial.
Hargreaves said the surgery went forward nonetheless, in the
belief that coverage would be granted on appeal.
But it wasn’t. In its denial, OneShare focused on her 2019
checkup, when her primary care physician wrote that Hargreaves had
“osteoarthritis in both hips,” based on Hargreaves’s own description of pain
and reduced mobility.
“If I knew [OneShare] was this difficult and restrictive, I
would have stayed clear of it,” she said. “Now my stomach is in knots. It’s a
big hit.”
OneShare declined to discuss Hargreaves’s case with me, but
in its communications with her it said she showed the “signs and symptoms” of a
preexisting condition during her checkup.
OneShare defines preexisting condition broadly: “Any
sickness or injury for which a member received medical treatment, advice, care
or services, including diagnostic measures, took prescribed drugs or showed
signs and symptoms, whether treated or not.”
OneShare has now offered to help negotiate on Hargreaves’s
behalf with her medical providers “in an effort to reduce [her] expenses.”
“It’s a cautionary tale,” said Renee Landers, director of
the health law concentration at Suffolk Law School. “When purchasing health
coverage, people need to understand that a lower-cost product may have
significant limitations or may not be a regulated insurance plan.
“They should consult their state’s insurance regulator for
advice or warnings about products they are considering,” she said.
Good advice.
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