She thought she was buying health insurance. She learned a $40,000 lesson

Mar. 4--Susan Calvin was healthy. Her family was, too. But their health insurance premiums and deductibles were climbing. When she started shopping for an insurance plan for 2017 and lamented the cost, Calvin says, her insurance broker suggested trying another option.

What she didn't fully realize at the time was that she wasn't buying health insurance. She was signing up for a health care sharing ministry.

A few years after dropping her health insurance and joining a sharing ministry, she warns, "My biggest thing with this is be very, very careful and cautious."

Health care sharing ministries are basically faith-based clubs whose dues are pooled and distributed to help members pay their medical bills. The ministries require members to adhere to certain faith-based principles -- no illicit drugs, heavy drinking or extramarital sex, for example -- and to follow certain rules laid out in their contracts.

The ministries gained popularity under the Affordable Care Act. The law's tax penalty for going uninsured rolled out in 2014, and it did not apply to people who joined health care sharing ministries. That exemption -- and the rising costs of not only having health insurance but using it, too -- made the ministries popular with people like Calvin, who don't have coverage through their jobs and don't qualify for income-based subsidies to buy their own insurance.

The number of Idahoans in health care sharing ministries has grown significantly in recent years, according to Idaho Department of Insurance Director Dean Cameron. The department asked eight of the largest ministries to divulge how many Idahoans they cover.

There were 15,874 Idahoans in those eight ministries in 2017. There were 24,282 in 2018. Cameron doesn't yet have the numbers for 2019, but he thinks it could be 35,000 or more

"I would not be surprised if it was that high," he said.

That's about one-third the number of Idahoans who bought health insurance plans through the state exchange that year.

"From a philosophical standpoint, I have absolutely no objection to religious institutions assisting individuals with their health care needs, whether they're assisting them with paying their claims or assisting them with paying their premiums," Cameron said.

What does give him "heartburn," he said, are complaints from people like Calvin, whose claims weren't covered as they would have been by health insurance -- and who were left with five- or six-figure medical bills.

He says Idahoans need to take a "buyer beware" approach and understand the limits of their coverage in a health sharing ministry.

Claims denied by health care sharing ministry

Susan Calvin, of Boise, looked over her contract when she joined Texas-based Altrua HealthShare, but she doesn't remember noticing some of the fine print about what it would and wouldn't cover. What she does remember noticing was the member dues -- less than half of what she'd been paying for health insurance, she said, with a "reasonable" deductible.

She signed up. That was December 2016.

A month later, she got sick. Very sick. She went to the emergency room with what she thought was a sinus infection.

She contacted Altrua the week after her ER visit, she said. She learned her first lesson: the ministry wouldn't pay, because she didn't submit the claim fast enough, she said. (Altrua documents from that year said members with ER visits must contact Altrua within 96 hours of discharge.)

The illness didn't go away. As the months went on, her symptoms worsened. Her tongue went numb. Her foot went numb.

Calvin's doctor suggested surgery. The procedure was expected to cost $17,000 -- and Altrua told her it wouldn't cover the bill, she said. Faced with the massive expense, she almost backed out, but her husband insisted.

So in December 2017, a year after joining the health sharing ministry, she had sinus surgery. The surgeon discovered the cause of Calvin's problems wasn't a sinus infection, or a deviated septum, or anything else they'd speculated it could be. It was an extremely rare vascular condition that can be fatal without treatment.

"Essentially, my septum had disintegrated," she said.

The surgeon told Calvin she "either was a heavy drug user, which I am not, or I had Wegener's disease, where my white blood cells were attacking my body," she said.

Wegener's disease, also known as granulomatosis with polyangiitis, is a condition that affects blood vessels and tissue in certain parts of the body, including the sinuses.

"It cut off all the blood circulation (in my sinus area) and it was getting into my lungs, and that's where it's fatal," Calvin said. "If I had waited two or three months, I would have died."

She ended the year with $40,000 of medical bills, she said.

Getting the condition under control would require infusion treatments. Drugs that cost $300,000 a year. Hundreds of thousands of dollars a year in medical costs, she estimates.

Calvin dropped Altrua and signed up for a plan through Idaho-based Mountain Health CO-OP, which sells Affordable Care Act-compliant health insurance plans on Idaho's exchange. The Affordable Care Act requires insurance plans sold on exchanges to cover preexisting conditions, and prohibits them from charging people more based on past health problems, so Calvin's lack of insurance the prior year had no effect on her coverage. Health sharing ministries have no such requirements.

"I'll be forever indebted to them," Calvin said of Mountain Health CO-OP.

Her monthly premium doubled to about $1,200 a month, she said. "But considering how much the treatments were, I didn't blink an eye. ... I would have been bankrupt if I'd stayed with the other company."

Calls and emails to Altrua were not returned.

The company's website includes a set of questions and answers that make it clear it is not health insurance.

"No, we are NOT an insurance company nor is the membership offered through an insurance company, and our organization is not subject to the regulatory requirements or consumer protections of any state insurance code," it says.

The website also provides Altrua's membership guidelines that, for 2017, said cases of sinusitis were not covered. That's consistent with what Calvin says Altrua told her. She says she tried to appeal but the company didn't respond.

"I turned in all my medical bills (to Altrua), I showed them it wasn't a sinus infection that caused it, it was Wegener's" but Altrua declined payment, she said. "So I sent all my (stuff) to the legal department, nothing."

What can Idaho do about health sharing ministries?

Cameron, the top health insurance regulator for Idaho, told the Statesman that he has heard similar complaints from around the state.

"I heard one, the other day, from some people down in Burley, where they had been told to go ahead and pay their $200,000 claim, and that the (ministry) would reimburse them," he said.

That was a year ago, and they're still waiting for the money, he said.

A woman in Soda Springs said her ministry denied coverage for her liver transplant "because she had drank alcohol in her life," Cameron said.

Another person told Cameron their claims were denied because the ministry decided the person "was one religious belief that was slightly different" from the one with which the ministry affiliated itself.

"Consumers need to be very wary," he said. "They need to read ... the provisions very carefully. They need to document what the salesperson or the agent is telling them about the contract. And make sure they keep good notes and records."

Cameron said consumers should ask: Under what conditions can they deny a claim? Can they deny a claim because of my religious affiliation? What's the preexisting condition clause? Does the patient have to pay the claim up front, then get reimbursed?

The faith-based status keeps the organizations from having to follow the same regulations as health insurers. The ministries don't have to cover medical care for certain things. They don't have to prove their financial strength or their ability to pay on claims.

The Idaho Legislature in 2013 codified the criteria for a health care sharing ministry, such as including a disclaimer on their materials that tells customers they're not buying insurance and have no guarantees that their bills will be paid.

"I also have a concern that, for some of these programs, that they can remain financial viable," Cameron said. "And maybe the way they remain viable is simply by denying claims. So those are both strong concerns we have."

Other states have begun to push back against, or warn people to stay away from, bad actors.

Some have warned consumers to be careful or even gone so far as to sue health sharing ministries. Washington state last year banned Trinity Healthshare, one of the largest ministries in the U.S., from selling there and issued a $150,000 fine. The state's insurance commissioner said Trinity sold collected $3.8 million in premiums from more than 3,000 Washington residents.

"Frankly, we're trying to figure out how to handle it" in Idaho, Cameron said. "We're trying to follow the intent of the Legislature as well as what the code actually says. And so, we're in the process of reviewing what to do ..."

He encourages anyone with a complaint to reach out to him directly at [email protected] with information about the company and their experience.

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