Wednesday, July 6, 2016

Is There Such A Thing As Affordable, Accessible Health Care? Maybe.

We replaced our family's Aetna health insurance plan with a Healthcare Sharing Ministry [HSM]* four years ago. 

For our family, we chose Samaritan Ministries International [SMI] as the most affordable option with the most accessible care. We pay $495 a month, and a medical need over $300 is covered 100%.

HSM's definitely aren't for everyone, but if you're curious how SMI works for our family of seven, here you go:**

Overview

HSM's are basically self-insured insurance plans run as co-ops. Each member gives a standard monthly amount, which is distributed among all of the other members with health care needs that month. There is a central office that processes medical needs and distributes all members' contributions for the coming month.

Samaritan Ministries International has been following this system since 1994, and all health care needs within the guidelines of their program have been covered in full.

SMI has its own language, without using traditional insurance terms of "premium" (the monthly cost of a plan), "deductible" (the amount paid by an individual before insurance helps), "co-insurance" (the amount paid by an individual after deductible is met), or "co-pay" (cost for an office visit). Nonetheless, I'll use these terms as I describe how an HSM works for us.

Membership

To support a healthy community, members sign a commitment to practice healthy living according to the organization's guidelines, which are based on biblical principles. Members also sign a faith commitment that they are practicing Christians who desire to help other Christians with their medical needs. 

Not all HSM's are Christianity-based. I provide some links below for other options. 

Premiums

Our family pays $495 a month as a "premium." In SMI, this is called a "share." Each month we send $495 to another member of SMI to help cover their health care need. 

Below are monthly share ("premium") amounts: 

One person: $220
Two person family: $440
Three or more person family: $495
Widowed or divorced with children: $305  

Deductibles

If a member has a health care need that's over $300, it's covered 100%. (Most private health insurance plans have annual deductibles from $1,000 - $12,000 per person. My husband's employer-sponsored plan has a deductible of $5,000 per person. This would add up quickly in a family of seven with multiple medical needs in a given year.)

With SMI, the $300 deductible per healthcare need includes maternity. To re-phrase: having a baby costs an SMI family $300 out-of-pocket. Same thing for a kidney stone, appendectomy, ER visit, heart attack, or any covered medical need.

A family's annual maximum out-of-pocket is $900, for medical needs covered by SMI.

Networks

There is no such thing as "In-Network" or "Out-of-Network" for SMI members. You choose your healthcare providers, and the medical need is covered, if it's over $300. 

(This is such a relief for us, because on a prior plan, our son's pediatric ENT was in-network, but not the pediatric ophthalmologist. My ob-gyn was in-network, but not the lab. For many people, a hospital might be covered in-network, but the ER doctors at the hospital are out-of-network.)

Co-Insurance

There is no co-insurance. Once the $300 deductible is met per medical need, or the maximum annual limit of $900 per family, the medical need is covered 100%. 

(My husband's employer-sponsored plan has an 80/20 co-insurance plan, which means insurance covers 80% of medical bills, once an individual has reached their deductible. The family is still responsible for 20% of the bill, up to their annual maximum out-of-pocket. I think the maximum annual family out-of-pocket on our employer-sponsored plan was $12,000.) 

Co-Pays

Members of HSM's present as self-pay patients for medical providers. Most medical providers have a self-pay rate that's a significant discount, since they don't have to deal with insurance paperwork. 

Our pediatrician used to charge us $80 for a sick visit. CVS Minute Clinics are $89 - $99 a visit. Walgreens sick visits are $89 - $129. Walmart Care Clinics are $59 a visit. 

I think a co-pay on my husband's insurance would be $70 a visit, so it's not that much more to just self-pay.

Prescriptions

Prescriptions are only covered as part of a medical need for 6 weeks after the need.

For long-term prescriptions, such as asthma inhalers, we use a discount card, among which there are many free programs to choose. Most pharmacies have several discount cards by the register. I have them run these options until we figure out which one gives us the best price on a given prescription. 

I've also gone to pharmaceuticals' websites to print coupons.

Wellness Care

SMI does not cover wellness care. (Private health insurance covers wellness care 100%. This would be nice, but as it turns out, it's better for our finances to just pay out-of-pocket for wellness care.)

We use the county health clinic for wellness visits and vaccinations, which cost $5 per visit. Many doctors' offices offer self-pay discounts, or a sliding scale based on income.

Premium Increases

There are no arbitrary or unexpected monthly premium increases. If members' health care needs surpass the available shares in three consecutive months, then all of the members vote on whether to increase monthly shares. Seriously, you vote on premium increases. Nobody likes an increase in medical costs, but the transparency with SMI is refreshing.


When we joined in 2012, a family of three or more members paid $355 each month. We voted on a share increase to $370, and then in 2014, we voted for another share increase to $405 each month. Two years later, the premium is now $495 per month for a family.

Pre-Existing Conditions

This gets complicated, but for the most part, pre-existing conditions are not covered. This sucks. (Traditional health insurance is required to cover pre-existing conditions.) 

Also not covered: dental and vision. (Usually private health insurance requires additional plan purchases to cover these.)

Billing and Paperwork

Since members are self-pay patients, ALL of the medical bills come directly to you. It can be overwhelming. 

Once a medical need is over $300, bills are submitted to SMI. SMI partners with a third party agency that advocates on members' behalf to negotiate lower bills with medical providers, if a discount hasn't already been given. From the central processing office, your medical need is shared with SMI members. 

And then you literally receive checks and "Get Well" cards in the mail throughout the month, as members send their monthly shares to support your medical need. You use this money to reimburse or pay medical providers.

Being a member of SMI is definitely paperwork heavy when there's a medical need. We have to stay very organized, with diligent communication with our healthcare providers.  
CMF Curo is an add-on program to Samaritan Ministries that takes care of all the paperwork and billing. It's an appealing structure, but not in our budget for something we can cover ourselves with just a little more work. 

Does It Work? 

Yes. Here's a link to how it covered an ER visit three years ago: The Kidney Stone Story. This link provides more detail on the billing and discount process for self-pay patients.

I wish I had written up my son's adenoidectomy experience, because that occurred just after the government subsidies became available for health insurance on the exchange, and many people were realizing that the exchange plans were sub-par. Several billing specialists noted that it was easier for us to schedule surgery, and the surgery itself was less expensive with self-pay discounts, than for patients who had purchased a high-deductible insurance plan.

Compared to health insurance premiums, our monthly shares are very low. And we can budget the money saved on premiums, deductibles, and co-insurance for wellness care and medical needs under $300.
 

 Why Do People Join?

Over 60,000 families participate in our HSM, most of whom joined for one of the following reasons: 

1. They're disillusioned or strongly disagree with how health care is run in the United States. 

   This can be a philosophical disagreement with the insurance system in general, or with the accessibility and affordability of health care.


2. Employer-sponsored health insurance plans are not available to everyone. 

   Many companies keep employees at 29 hours a week to avoid mandated benefits coverage. Many small businesses or self-employed individuals can't access group plans from the insurance companies.

3. Exchange health insurance plans are not available to everyone.  

   If an employer offers health insurance to employees, the employees are not eligible for plans on the government exchange, even if the exchange would offer better or more affordable coverage.

4. Premiums for employer and exchange plans are too high. 

   Even accounting for employer stipends and government subsidies, premiums quickly reach more than families can budget each month.

5. Deductibles for employer and exchange plans are too high. 

   For the employer-sponsored plan available to our family, at a premium we could afford, the individual deductible is $5,000 per year. This might be in our budget, if only one of us had a health crisis any given year. But there are seven of us, and I don't want to play those odds.

6. Out-Of-Network medical providers cause financial and administrative stress. 

   The in-network and out-of-network games of insurance companies means your preferred caregiver might cost three times as much, even with health insurance. Or, as recent news stories have covered -- even if a hospital is in someone's network, ER doctors are often contracted to the hospital, and inevitably, out-of-network. This turns into very expensive emergency care. 

Other Options 

There are several other HSM's, besides SMI. I would encourage anyone who's thinking about transitioning to look into all of them: Christian Care Ministry (Medi-Share), Christian Healthcare Ministries, Liberty HealthShare, Altrua HealthShare, Solidarity Healthshare, and the Samaritan Ministries add-on program, CMF Curo.

In Conclusion 

Transitioning to an HSM is scary. Our national health care system runs on private health insurance, for better or worse. 

We actually spent our first several months on SMI paying for both SMI and private health insurance, because we couldn't wrap our minds around the jump we were about to take. 

The deciding factor for us was the loss of our private health insurance, when I changed to part-time work after our second child was born. 

Update

Due to a very generous employer-sponsored plan, we are currently using private health insurance. Should our job situation change, or the private health insurance prove insufficient or unaffordable, we will definitely return to a healthcare sharing ministry. 

We would happily return to Samaritan Ministries. We would also consider Solidarity Healthshare, which is less expensive, with less billing paperwork and good coverage. We have heard negative feedback from friends who have used Medi-Share, but do not have personal experience with them. 

Please don't hesitate to reach out to me with any questions. You can comment below, and I'll respond, or email me directly at charlene.bader@gmail.com .



*HSM's qualify as an exemption from the individual mandate in the Affordable Care Act, which requires everyone to carry private health insurance. HSM's fulfill this mandate.

**Disclaimer: Please, friends, look up and verify all of this information. It's very accessible on the Samaritan Ministries International website. I'm sharing how this HSM has worked for our family, but I also haven't slept in years, so readers are responsible for verifying any of this info.

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