Health Share

I get many calls from people who cannot afford their health-insurance, who are concerned about whether or not it is “safe” or “better” to subscribe to a health-share.  In this article I will address some of the major differences between insurance and health shares and also layout the risks and benefits of joining a health share.

What is a health share?

A health share is essentially a co-op of members who pool funds to pay each other’s medical expenses. By joining, each member contributes a monthly amount to a pooled fund and medical expenses or “needs” are then paid out of that fund. Health shares typically either have dedicated annual fees for administration or charge some small, usually less than 10%, percentage of the monthly fee for administrative expenses. Health shares do not make a profit: excess funds after member-needs are paid are returned to the fund.

Historically, health shares started as Christian ministries, normally restricted to those who avowed specific beliefs in Christian faith, that were used instead of health insurance by members. Some examples of these are Liberty Health Share and Samaritan Ministries. The ACA grandfathered in existing health shares, at that time all Christian, as acceptable substitutes for health insurance. Since the ACA some secular health shares have emerged, like Zion and Sedera, which do not require any statement of faith or membership in a church of any kind. These are not included in the ACA exemption and these health shares probably do not qualify as they are not “ministries” (I’ll know for sure if they qualify for California’s penalty after I file my 2020 taxes).

How does the health share work?

Once you are accepted for membership in a health share, you will contribute your monthly amount every month. These amounts are typically much less expensive than standard health insurance. If something should happen to you, like you break an arm, you would go to the emergency department or urgent care as usual. While there, most health shares have you show your card and declare yourself as a cash paying patient.

Depending on the health share, either you get the bills and submit a “need” to your health share or the bill goes directly to the health-share administration. They then (usually) negotiate the cost down, and pay everything except your unshared amount (UA). It is important to understand that the UA is not a deductible. For many plans, there is no annual limit to the UA, it applies to each discrete episode requiring healthcare. So for instance, if you break your arm in March, get diagnosed with cancer in May, and get a heart attack in December unrelated to your cancer, you will have to pay a UA for each of those events. The health share will pay everything else, for as long as you need treatment. Sometimes the health share will pay the hospital and doctors directly, and sometimes they will pay you after you have paid the bill.

Do health shares cover pre-existing conditions?

This varies based on the health share, but most will gradually grandfather in pre-existing conditions. I haven’t found one that will cover a pre-existing condition immediately. Some will begin covering percentages of pre-existing conditions, increasing annually until the condition is fully covered. However, health shares are completely free to decline to cover pre-existing conditions for the life of your membership. The ACA does not apply to health shares in terms of coverage for birth control, pre-existing conditions, or anything else. That said many of the things the ACA requires coverage for actually quite inexpensive when you are paying cash. For instance oral birth control pills can be bought for less than $10 a month at Blink Health.

Do health shares have to cover my health care bills?

No. The health share actually has no legal obligation to cover any of your bills. When you choose to be a member in a health share you are relying on good faith and trust in the community you have joined. Since they exist only to cover members’ bills, legitimate health shares will cover your bills for as long as the bills fit within their guidelines and they continue to have money in their fund. If a situation arises where many members have major bills, the health share may start to limit how much they’ll pay out for each member in order to cover as many as possible. Further, health shares also often limit what they will pay for based on a morals basis. So, for instance, if you get into a car crash and are severely injured because you were intoxicated, they may decline to pay your bills.

However, you may have noticed that insurance companies don’t seem to feel they have to cover your healthcare bills either. Increasingly, for-profit insurance companies are declining to cover all or part of patients’ bills for less and less legitimate reasons. I have seen ER bills for patients coming in with a complaint of abdominal pain get denied because the abdominal pain was ultimately diagnosed as something non-emergent. Meanwhile, for-profit insurance companies are posting higher and higher profits. Profits have been even higher during the COVID -19 pandemic.

Can I save money using a health share?

It depends but, usually, yes, you will pay significantly less every month for health share than you will pay for standard health insurance. You have to weigh this against whether or not you have expensive pre-existing medical conditions in your family, and the risk that the health share will decline to pay something based on the morals clause. Every patient and family needs to make this decision for themselves.

Additionally, it turns out that being a cash-pay patient can be surprisingly inexpensive compared to paying for health-insurance monthly. I am able to get my patients inexpensive lab tests and radiology studies as cash-pay patients. For inexpensive medications I use Blink Health and direct my patients to GoodRX (although GoodRX may be selling patient-data). Often, what my patients pay directly for these tests and medications is less than what they would pay as a co-pay through insurance.

Joining a health share requires a significant amount of trust in the organization that you are joining. I only recommend reputable health shares on my website and in person. These include Sedera, Samaritan and Zion Health. Liberty has existed for a long time, and does, eventually, pay. However they have recently significantly raised their membership rates and they are still having difficulty catching up to their growth administratively – so their payments can often take months to make it to you or your doctor. Some health shares have been banned in certain states due to misleading marketing or failure to pay.

Do I have to get prior authorization or go to my primary care doctor first before seeing specialists?

This depends on the health share. Some health shares will require a telemedicine second opinion, like Sedera. Other health shares will allow you to go directly to the specialist without any prior consultation. Health shares that work heavily with Direct Primary Care (DPC) practices tend to require patients to go to their DPC doctor prior to going to see specialists. Some health shares will share chiropractic and alternative healthcare practitioners and some will not. In general, health shares do give patients more freedom to choose their doctor, their specialists, and their preferred healthcare modality than traditional insurance.

How do health shares work with Direct Primary Care practices?

Many health shares are recognizing the cost and quality benefits of Direct Primary Care. Some, like Zion, offer direct discounts for patients who are members of a DPC. Sedera normally operates through employers and will only offer individual memberships to DPC members. Still others will give DPC members a rebate for membership. Every health share is different and you need to check with your particular health share prior to determining how you will combine it with a DPC or traditional insurance-based practice.

Can I get a health share plan for my employees instead of insurance?

There are health shares that offer employer-based plans. Obviously, you need to understand what the law requires in terms of the ACA and state laws as to whether this is the right plan for your business. Self-insured companies might find a health share combined with a direct primary care practice a good fit for their bottom line as well as the well-being of their employees. I address employer DPC plans further on my article on direct primary care and businesses. Since I wrote that article more health share organizations have started offering employer-based plans. Both Sedera and Zion Health have employer plans.

What if I quit my job and I have health share through my work?

One of the absolute best things about health shares is that you can keep your membership regardless of your employment status. As long as you pay your monthly share amount you can remain a member in good standing. This gives you significant freedom as an employee to leave jobs you find dissatisfying without first having to find another job that will offer you health insurance.

In Conclusion

If you are relatively healthy or have something limited like hypertension or type II diabetes, a health share may be the right choice for you. You just need to go into it with your eyes open, understanding that they are under no legal obligation to cover your expenses. Health shares, like your relationship with your doctor, are based on mutual trust.

For a comparison between five of the most prominent plans, click here.

For a comparison of health share member reviews, click here (please note, I have no idea who is behind this website, so I won’t vouch for reliability).

If you have more questions about health shares please call me at 760-425-4466 or email me at DrEdwards@wowhealingcare.com.