Our experience with a healthcare sharing ministry

[SmallCityDave]

It seems some on this forum have a negative opinion of these ministries when they look at them through the lens of government funded insurance (which it's not) I'd like to share our personal journey.

I'm going into this with eyes wide open (at least I'm under that impression). First what it's not, it's not government funded so we can't spend more than it takes in, it doesn't cover abortions, drug rehab programs, preexisting conditions or routing visits. What it is is a group of like minded Christians sharing the cost of large medical bills and it's affordable.

It's not for everyone and it's not intended to be.

Our Story:

The issue at hand is in the gray area, we've known about this condition before we signed up for the cost sharing ministry however the doctors didn't think it would require surgical intervention but about 8 months ago we found out that surgery was needed sooner than later, we didn't anticipate the procedure would be covered but now it appears it will.

Six weeks ago we had a fairly significant surgery with 5 days in the intensive care unit, we were told the cost would be about $50k (we can handle that but it would be a little tight). We are tallying up the bills and it appears to be a little over $200k.... luckily since we are considered cash pay we get some discounts and if my math is correct it should be around $70k.

The way the program works is we pay upfront and submit the bills for reimbursement, currently we've paid about 20K and it appears that we're approved to get back at least $10k. I'm confident it will be a lot more than $10k but the way the system is set up we need to submit paid itemized bills and the healthcare providers are a little slow to send us the bills in the format that's required.

I'm happy to answer any questions and if there is interest I'll update this thread as this ordeal unfolds.

[Horsefly]

I'm not sure I get your comment about "government funded". I think the gov't funds insurance for gov't employees and provides subsidies under the ACA, but other than those two I think the only thing the gov't does is put requirements on what is called "Health Insurance". Those requirements provide a level of consumer protection and underwriting / funding to make sure the insurance does what it says it can. I'm pretty sure that gov't doesn't fund any of my insurance with Anthem. Am I wrong?

I don't really know much about HSMs, until I just read some stuff on line. Seems like the biggest risk is that it goes belly up or - due to funding - changes what they will pay for. I guess if you are in a big enough HSM, that would lessen the risk.

[tashnewbie]

I hope you get all of your bills paid.

I don't have any experience with HSMs and don't know much about them.

My quick observation is that for some people, using a HSA-compatible HDHP might be cheaper and provide more consistent and broader coverage than using a HSM. I don't know if that's true.

[Devil's Advocate]

I hope you get all of your bills paid.

I don't have any experience with HSMs and don't know much about them.

My quick observation is that for some people, using a HSA-compatible HDHP might be cheaper and provide more consistent and broader coverage than using a HSM. I don't know if that's true.

For me that is not true. I am on a HDHP and HSA at my employment for me only and I pay around $300/mo for insurance. I pay $300/mo for Christian HCM for family. That $600/ mo is half of what my employer's family plan would be...

After 2 years we have not used my insurance or the HCM. Therefore I dont really have an opinion if the HCM is a good idea.

DA

[galawdawg]

Can you share the details so that this might be actionable for others?

Monthly costs, reimbursement limits (percentage, fixed amount, and such), other non-covered amounts, prescription coverages, those types of things?

It would be interesting to compare out of pocket costs for the HSM to traditional health coverage.

[tashnewbie]

I hope you get all of your bills paid.

I don't have any experience with HSMs and don't know much about them.

My quick observation is that for some people, using a HSA-compatible HDHP might be cheaper and provide more consistent and broader coverage than using a HSM. I don't know if that's true.

For me that is not true. I am on a HDHP and HSA at my employment for me only and I pay around $300/mo for insurance. I pay $300/mo for Christian HCM for family. That $600/ mo is half of what my employer's family plan would be...

After 2 years we have not used my insurance or the HCM. Therefore I dont really have an opinion if the HCM is a good idea.

DA

Note I said it *might be cheaper for *some people. It's really a speculation on my part. I have no clue what the statistics really bear out.

For me, I pay $72/month premium for a HSA-compatible HDHP. I don't know what my monthly premium might be in a HSM.

[SmallCityDave]

I'm not sure I get your comment about "government funded". I think the gov't funds insurance for gov't employees and provides subsidies under the ACA, but other than those two I think the only thing the gov't does is put requirements on what is called "Health Insurance". Those requirements provide a level of consumer protection and underwriting / funding to make sure the insurance does what it says it can. I'm pretty sure that gov't doesn't fund any of my insurance with Anthem. Am I wrong?

I don't really know much about HSMs, until I just read some stuff on line. Seems like the biggest risk is that it goes belly up or - due to funding - changes what they will pay for. I guess if you are in a big enough HSM, that would lessen the risk.

Best (but not only) example of government funded is Medicare. Medicare doesn't have to worry about a budget they just spend and they pay providers whatever they want unlike us, if the provider gives us a bill for $500 we have to pay it if Medicare gets a bill for $500 they could pay $100 or $7 and there is little recourse. Healthcare providers don't have to participate but if they do there are a lot of strings attached.

[Devil's Advocate]

I hope you get all of your bills paid.

I don't have any experience with HSMs and don't know much about them.

My quick observation is that for some people, using a HSA-compatible HDHP might be cheaper and provide more consistent and broader coverage than using a HSM. I don't know if that's true.

For me that is not true. I am on a HDHP and HSA at my employment for me only and I pay around $300/mo for insurance. I pay $300/mo for Christian HCM for family. That $600/ mo is half of what my employer's family plan would be...

After 2 years we have not used my insurance or the HCM. Therefore I dont really have an opinion if the HCM is a good idea.

DA

Note I said it *might be cheaper for *some people. It's really a speculation on my part. I have no clue what the statistics really bear out.

For me, I pay $72/month premium for a HSA-compatible HDHP. I don't know what my monthly premium might be in a HSM.

Note I said for me it is not cheaper.

DA

[stan1]

Did OP decline their employer health care or do they have jobs that do not offer employer health care benefits? For the latter group yes ACA compliant plans are expensive so if you can figure out ways to get yourself into a healthier pool and accept the risk that some services you need might not be covered (no pre-existing conditions, maybe fewer smokers, maybe younger) your rates should be less. I think there's overlap with the group of people who had high deductible, limited coverage plans prior to ACA (not to be confused with HDHPs which are ACA compliant). Group might include self-employed and small business owners.

[Jack FFR1846]

So this is not insurance but saying they are insurance? With the violations of ACA, I can see why they can't be actual insurance. Sounds to me like simple fraud.

[tashnewbie]

I hope you get all of your bills paid.

I don't have any experience with HSMs and don't know much about them.

My quick observation is that for some people, using a HSA-compatible HDHP might be cheaper and provide more consistent and broader coverage than using a HSM. I don't know if that's true.

For me that is not true. I am on a HDHP and HSA at my employment for me only and I pay around $300/mo for insurance. I pay $300/mo for Christian HCM for family. That $600/ mo is half of what my employer's family plan would be...

After 2 years we have not used my insurance or the HCM. Therefore I dont really have an opinion if the HCM is a good idea.

DA

Note I said it *might be cheaper for *some people. It's really a speculation on my part. I have no clue what the statistics really bear out.

For me, I pay $72/month premium for a HSA-compatible HDHP. I don't know what my monthly premium might be in a HSM.

Note I said for me it is not cheaper.

DA

Fair enough. Have you compared your expected total out of pocket costs under both your employer-sponsored plan and the HSM? You said you haven't had to use either, but if you ever did, what would the differences look like?

[Devil's Advocate]

So this is not insurance but saying they are insurance? With the violations of ACA, I can see why they can't be actual insurance. Sounds to me like simple fraud.

They are very careful to say that are not insurance. They simply share the cost of health care amongst their group. I had not found a substantial number of people upset with them online. Most of those that complain did not provide the HCM the correct forms, bills etc.

DA

[stan1]

After 2 years we have not used my insurance or the HCM. Therefore I dont really have an opinion if the HCM is a good idea.

Sounds like you and family are fortunate to have good health, maybe much better than average. Would you be able to transition family back to your employer insurance if they needed it? If so then decision to move them off to HSM is a lot easier.

[Devil's Advocate]

I hope you get all of your bills paid.

I don't have any experience with HSMs and don't know much about them.

My quick observation is that for some people, using a HSA-compatible HDHP might be cheaper and provide more consistent and broader coverage than using a HSM. I don't know if that's true.

For me that is not true. I am on a HDHP and HSA at my employment for me only and I pay around $300/mo for insurance. I pay $300/mo for Christian HCM for family. That $600/ mo is half of what my employer's family plan would be...

After 2 years we have not used my insurance or the HCM. Therefore I dont really have an opinion if the HCM is a good idea.

DA

Note I said it *might be cheaper for *some people. It's really a speculation on my part. I have no clue what the statistics really bear out.

For me, I pay $72/month premium for a HSA-compatible HDHP. I don't know what my monthly premium might be in a HSM.

Note I said for me it is not cheaper.

DA

Fair enough. Have you compared your expected total out of pocket costs under both your employer-sponsored plan and the HSM? You said you haven't had to use either, but if you ever did, what would the differences look like?

I think my deductible is 8k or so for HDHP

My expected contribution (deductible) for HCM is 10k.

I am not sure on co pays, total out of pocket costs.

We are not users of health care in general. (So far)

DA

[SmallCityDave]

Can you share the details so that this might be actionable for others?

Monthly costs, reimbursement limits (percentage, fixed amount, and such), other non-covered amounts, prescription coverages, those types of things?

It would be interesting to compare out of pocket costs for the HSM to traditional health coverage.

You bet.

Monthly cost is just over $500 per month for our family of 4, no reimbursement limit, $400 out of pocket for a covered event and no prescription coverage.

It's hard to compare of what I would have paid due to my pre-existing conditions because I was denied coverage the last time we shopped, I can't see us paying anything less than $1000 per month. Our "normal" doctor visits are $24 per and I pay less for my prescriptions now than my co-pay when we had insurance.

[aristotelian]

You say your employer plan is not cheaper but did you look into ACA exchange plans?

Does the Ministry plan have a maximum out of pocket? ACA plans are in the $13k range.

If you are seeking to make this relevant to people considering this option, it would be helpful if you state at the outset the premium, deductible, and max out of pocket (if any). You could also share the same details of your employer plan and ACA plans you were considering. What was your thought process in making the choice for the Ministry?

[Devil's Advocate]

After 2 years we have not used my insurance or the HCM. Therefore I dont really have an opinion if the HCM is a good idea.

Sounds like you and family are fortunate to have good health, maybe much better than average. Would you be able to transition family back to your employer insurance if they needed it? If so then decision to move them off to HSM is a lot easier.

I'm in the health care industry. I for better or worse take care of the small issues my family has (laceration repairs, ear infections, etc) Other than my personal CA hx 15 or so years ago we just don't need much care (so far, fingers crossed)

DA

[Elsebet]

I like the idea in general but am not religious and disagree with a lot of the tenets most HSMs have. I googled and it doesn't seem there are many options other than religious, maybe we should start a secular Bogleheads HSA (health sharing association).

[tashnewbie]

I like the idea in general but am not religious and disagree with a lot of the tenets most HSMs have. I googled and it doesn't seem there are many options other than religious, maybe we should start a secular Bogleheads HSA (health sharing association).

I was wondering if there were any secular healthcare sharing orgs, too.

[ResearchMed]

It's hard to compare of what I would have paid due to my pre-existing conditions because I was denied coverage the last time we shopped, I can't see us paying anything less than $1000 per month. Our "normal" doctor visits are $24 per and I pay less for my prescriptions now than my co-pay when we had insurance.

I have no experience with these types of health care payment arrangements.

But what's this about being denied regular health care insurance coverage due to pre-existing conditions "last time" you checked?

How long ago was that?

My understanding is that with ACA, there are no longer exclusions for pre-existing coverage.
Is this not correct?
I thought that this was a huge advantage of ACA for some who had no employer-type coverage but who did have pre-existing conditions.

How the costs would compare is a separate issue.

RM

[Chuck]

I like the idea in general but am not religious and disagree with a lot of the tenets most HSMs have. I googled and it doesn't seem there are many options other than religious, maybe we should start a secular Bogleheads HSA (health sharing association).

I 100% agree that you should have the right to do that. Unfortunately, the ACA makes it illegal to start a new health care cost sharing association.

[inverter]

I like the idea in general but am not religious and disagree with a lot of the tenets most HSMs have. I googled and it doesn't seem there are many options other than religious, maybe we should start a secular Bogleheads HSA (health sharing association).

If I didn't have affordable, employer-provided coverage

[Devil's Advocate]

I like the idea in general but am not religious and disagree with a lot of the tenets most HSMs have. I googled and it doesn't seem there are many options other than religious, maybe we should start a secular Bogleheads HSA (health sharing association).

I am not religious either and would have no qualms about signing their agreements anyway. It's not like I'm afraid of going to h*ll for lying.

DA

[JoMoney]

I like the idea in general but am not religious and disagree with a lot of the tenets most HSMs have. I googled and it doesn't seem there are many options other than religious, maybe we should start a secular Bogleheads HSA (health sharing association).

I was wondering if there were any secular healthcare sharing orgs, too.

I don't know if it's still the case, but under the initial ACA there was an exemption for religious reasons on the penalties of not having an ACA compliant plan. If one had to pay the penalty AND the fees associated with a HSM it might impact the decision if it was being made only on a cost basis.

[Devil's Advocate]

I decided to buy my own insurance as well since they don't cover preexisting conditions (i had CA) and don't cover issues that arise from activities they don't agree with such as using alcohol and such.

DA

[TravelGeek]

I have no experience with these types of health care payment arrangements.

But what's this about being denied regular health care insurance coverage due to pre-existing conditions "last time" you checked?

How long ago was that?

My understanding is that with ACA, there are no longer exclusions for pre-existing coverage.
Is this not correct?
I thought that this was a huge advantage of ACA for some who had no employer-type coverage but who did have pre-existing conditions.

That is correct. Pre-existing conditions exclusion are not allowed in ACA-compliant plans.

Recent administrative decisions have allowed longer “short term” insurance plans available and allowed “back to back” renewals. Those are usually not ACA compliant and don’t cover pre-existing conditions. You wouldn’t find them on the Exchange, though. (source)

[Chuck]

I 100% agree that you should have the right to do that. Unfortunately, the ACA makes it illegal to start a new health care cost sharing association.

Sorry, I think I overstated this. A new association would not exempt you from ACA penalties. I'm sure it's perfectly legal to start one, but there would be no benefit if you're still paying penalties.

[boglegirl]

This is a bad plan for anybody who has pre-existing conditions or a lot of prescriptions, or a family that doesn't have the cash flow to pay large bills as they come up. The "ministry" that my friend is a part of encourages their members to pay bills up front for the cash discount and then get reimbursed, and I kid you not, tells them to set up a GoFundMe to cover it if they can't afford to pay upfront. So in addition to "sharing" the costs with other ministry members, you're also expected to share them with friends & family in general. My friend was literally setting up a GoFundMe campaign from her hospital bed.

I didn't ask her what happened to the $ she collected on her GoFundMe campaign after the ministry reimbursed her. The whole thing seemed really sketchy.

[Bob.Beeman]

Does your HSM cover pre-natal and childbirth care? I assume that they are pro-life and that they would therefore cover this regardless of the situation. For example teen age mothers and children adopted or placed for adoption.

Do you know how they handle this?

[Pandemic Bangs]

What it is is a group of like minded Christians sharing the cost of large medical bills and it's affordable.

This is an oxymoron ("large medical bills" and "affordable").

You of course don't need to be like minded, or spiritually homogeneous, or exclude two very low-cost services for feel-good reasons so I don't think those details are relevant.

This is just a shared risk pool. Do you have negotiating power with the payors? If you do not, then you are at an enormous disadvantage compared to traditional insurers. You are more like a church bake sale.

Note that a couple very expensive procedures can bankrupt even established insurers. Kaiser in one region was almost broken by a family that ate poison mushrooms. Every one of them needed liver transplants at the same time.

[Luke Duke]

What it is is a group of like minded Christians sharing the cost of large medical bills and it's affordable.

This is an oxymoron ("large medical bills" and "affordable").

You of course don't need to be like minded, or spiritually homogeneous, or exclude two very low-cost services for feel-good reasons so I don't think those details are relevant.

This is just a shared risk pool. Do you have negotiating power with the payors? If you do not, then you are at an enormous disadvantage compared to traditional insurers. You are more like a church bake sale.

Note that a couple very expensive procedures can bankrupt even established insurers. Kaiser in one region was almost broken by a family that ate poison mushrooms. Every one of them needed liver transplants at the same time.

From the OP's description it would appear that the only negotiating power is that you are considered a cash customer.

[InvestorDave]

This is just a shared risk pool. Do you have negotiating power with the payors? If you do not, then you are at an enormous disadvantage compared to traditional insurers. You are more like a church bake sale.

Isn't a "shared risk pool" exactly what insurance is? You pay money in with lots of other people in the event that you have an injury, then the plan will cover it. I looked into getting on a plan with Samaritan Ministries but unfortunately I had cancer a few years ago and it's a pre-existing condition until clear for 5 years. However, I have friends that are on a plan with that company and they have never had an issue having their claims covered. You can even pay a little extra per year to have no limits on the amount that will be covered. I'm sure not every company has the same track record though.

It's interesting to see all the people chiming in and saying these plans are a scam without any first-hand experience. ACA plans are incredibly expensive if you are self-employed with a family and you aren't low enough income to get a subsidy. In my state I was looking at ~$1500/month for a HDHP that has a family deductible of $13,000 before claims are paid other than a routine yearly check up. One of the biggest scams is how tightly insurance is tied to employment. Most people have no clue the amount of money that their employers are paying for them to have health insurance. There is no market to shop around and there is little incentive for insurers to lower prices because their profits are limited to a percentage of their revenue.

[InvestorDave]

This is an interesting read on the rise of health insurance premiums.

https://www.aeaweb.org/research/regulat ... loss-ratio

[BrooklynInvest]

So if you have a million dollars in healthcare costs you pay half a million? What happens if you don't have that kinda money?

[SmallCityDave]

What it is is a group of like minded Christians sharing the cost of large medical bills and it's affordable.

This is an oxymoron ("large medical bills" and "affordable"). The medical bills are large and the plan is affordable.

You of course don't need to be like minded, or spiritually homogeneous, or exclude two very low-cost services for feel-good reasons so I don't think those details are relevant. I thought it was relevant that's why I shred it.

This is just a shared risk pool. Do you have negotiating power with the payors? If you do not, then you are at an enormous disadvantage compared to traditional insurers. You are more like a church bake sale. Do you mean the health care providers?

Note that a couple very expensive procedures can bankrupt even established insurers. Kaiser in one region was almost broken by a family that ate poison mushrooms. Every one of them needed liver transplants at the same time. Duly noted

My response is in bold.

[Luke Duke]

So if you have a million dollars in healthcare costs you pay half a million? What happens if you don't have that kinda money?

You declare bankruptcy.

[mkc]

Six weeks ago we had a fairly significant surgery with 5 days in the intensive care unit, we were told the cost would be about $50k (we can handle that but it would be a little tight). We are tallying up the bills and it appears to be a little over $200k.... luckily since we are considered cash pay we get some discounts and if my math is correct it should be around $70k.

The way the program works is we pay upfront and submit the bills for reimbursement, currently we've paid about 20K and it appears that we're approved to get back at least $10k. I'm confident it will be a lot more than $10k but the way the system is set up we need to submit paid itemized bills and the healthcare providers are a little slow to send us the bills in the format that's required.

So...

You are thinking your "cash pay" billed amount will be $70K, but it could go as high as $200K, depending on the actual discount.

And you must pay this out of pocket first and get a paid itemized bill that you then submit and accept whatever reimbursement you are offered by the HSM.

Best case being you have $70K cash in an emergency fund that you can exhaust while waiting for some reimbursement and potentially worst case you need $200K cash in that emergency fund. But you also stated you could handle the original $50K cost estimate but it would be tight. So it sounds like you don't have $70-200K in the emergency fund and likely have to dip into investments to pay the $70K hoped for minimum outlay (which could result in capital gains and the associated tax cost).

That kind of uncertainty and risk gives me the willies.

[JoMoney]

So if you have a million dollars in healthcare costs you pay half a million? What happens if you don't have that kinda money?

I don't know what you're replying to, but if your insurance/coverage doesn't cover it, and you can't afford it, it would probably depend on the specifics of the situation. If it's an elective medical operation, you probably won't get it unless you arrange to finance it somehow. If it's for some emergency treatment you already received, you'll have to sort out the debt. Sometimes these things get settled for lower amounts, sometimes there are charitable gifts, sometimes it leads to bankruptcy.

[willthrill81]

This is just a shared risk pool. Do you have negotiating power with the payors? If you do not, then you are at an enormous disadvantage compared to traditional insurers. You are more like a church bake sale.

Isn't a "shared risk pool" exactly what insurance is? You pay money in with lots of other people in the event that you have an injury, then the plan will cover it. I looked into getting on a plan with Samaritan Ministries but unfortunately I had cancer a few years ago and it's a pre-existing condition until clear for 5 years. However, I have friends that are on a plan with that company and they have never had an issue having their claims covered. You can even pay a little extra per year to have no limits on the amount that will be covered. I'm sure not every company has the same track record though.

HSMs function as insurance even though they are not legally considered to be insurance. At least among the big players, I've heard more positive things about them from participants than I've heard from the big insurers.

It's interesting to see all the people chiming in and saying these plans are a scam without any first-hand experience.

I blame those reactions, which we've seen time and again in these sorts of threads, and they seem to be due to extreme skepticism more than anything else. With the tens of thousands (at least) of people in these plans, if non-payment of 'covered' issues occurred with any regularity, participants would surely hear about it, jump ship, and tell everyone else to stay away. That doesn't mean that you are guaranteed to have your 'claim' paid though, and that is off-putting to many here, who are very risk averse about such things.

[SmallCityDave]

So if you have a million dollars in healthcare costs you pay half a million? What happens if you don't have that kinda money?

I know they have provisions for that but I don't know what they are.

Our current bill is somewhere around $70k we could have paid it but it would have been tight so we setup a payment plan with the hospital as we get money back (from the HCM) we will pay the bill so hopefully in a few months we will be done. It's certainly a humbling position to be in, I know that the health care providers don't have to give me a discount and the HCM is not (necessarily) obligated to pay.

[JoeRetire]

We are tallying up the bills and it appears to be a little over $200k.... luckily since we are considered cash pay we get some discounts and if my math is correct it should be around $70k.

currently we've paid about 20K and it appears that we're approved to get back at least $10k

Yikes. Hopefully the final tally ends up getting money back at a higher rate than that.

[JoeRetire]

I 100% agree that you should have the right to do that. Unfortunately, the ACA makes it illegal to start a new health care cost sharing association.

Sorry, I think I overstated this. A new association would not exempt you from ACA penalties. I'm sure it's perfectly legal to start one, but there would be no benefit if you're still paying penalties.

What penalties?

[marcopolo]

Aside from the fact that there is no contractual guarantees, these plans probably work OK for most healthy people.
It does so by shifting more of the burden to the rest of society.
These good people of faith will reject any expenses (and maybe even applicants) related to pre-existing conditions. This improves their risk pool, but at the cost of making the rest of our risk pool worse. So, in a real way, they are being subsidized by the rest of society.

[Pandemic Bangs]

...if Medicare gets a bill for $500 they could pay $100 or $7 and there is little recourse. Healthcare providers don't have to participate but if they do there are a lot of strings attached.

This is what you are lacking, hence my comment upthread. So you are committed to paying full retail pricing.

It's low risk for you. As others have said, you just declare bankruptcy. Not so great for those doing the healthcare.

No mention here of the MOOP. ACA enshrined the MOOP, correct? That prevents "fake" insurance plans where you are "only" on the hook for one-half of infinity . Like this one.

This is really not a financial question; it is a ruse for restricting participants' access to certain types of health care. The OP's demographic is among the heaviest users, nationally, of the prohibited services so it's potentially coercive to minors, spouses, etc. There are other health systems that try to do that, too, which is why we have laws around these things.

[Nate79]

In general these plans are well regarded by those actually on the plans but they are severely bashed on BH. But you know what has repeated threads of posters getting the shaft? By their insurance companies refusing to pay claims. Time after time. So spare me the " insurance is government regulated " superior attitude. I have insurance thru my employer but if I didn't I would have no qualms to look at these type of plans.

[SmallCityDave]

Six weeks ago we had a fairly significant surgery with 5 days in the intensive care unit, we were told the cost would be about $50k (we can handle that but it would be a little tight). We are tallying up the bills and it appears to be a little over $200k.... luckily since we are considered cash pay we get some discounts and if my math is correct it should be around $70k.

The way the program works is we pay upfront and submit the bills for reimbursement, currently we've paid about 20K and it appears that we're approved to get back at least $10k. I'm confident it will be a lot more than $10k but the way the system is set up we need to submit paid itemized bills and the healthcare providers are a little slow to send us the bills in the format that's required.

So...

You are thinking your "cash pay" billed amount will be $70K, but it could go as high as $200K, depending on the actual discount.

And you must pay this out of pocket first and get a paid itemized bill that you then submit and accept whatever reimbursement you are offered by the HSM.

Best case being you have $70K cash in an emergency fund that you can exhaust while waiting for some reimbursement and potentially worst case you need $200K cash in that emergency fund. But you also stated you could handle the original $50K cost estimate but it would be tight. So it sounds like you don't have $70-200K in the emergency fund and likely have to dip into investments to pay the $70K hoped for minimum outlay (which could result in capital gains and the associated tax cost).

That kind of uncertainty and risk gives me the willies.

Sorry my explanation wasn't better. The bill was over $200k, we've negotiated it down to +/- $70k we may still get a bill or two as the health care providers have been taking their time to send us bills but I don't anticipate it will be much more than $70k. Unfortunately we aren't dealing with one doctor or one hospital it's about 6-8 different entities.

I just spoke with my wife and I had it wrong all you need is the itemized bill form the provider along with some other documentation and the HCM will start paying the bills but I'm ultimately responsible.

[SmallCityDave]

...if Medicare gets a bill for $500 they could pay $100 or $7 and there is little recourse. Healthcare providers don't have to participate but if they do there are a lot of strings attached.

This is what you are lacking, hence my comment upthread. So you are committed to paying full retail pricing.

It's low risk for you. As others have said, you just declare bankruptcy. Not so great for those doing the healthcare.

No mention here of the MOOP. ACA enshrined the MOOP, correct? That prevents "fake" insurance plans where you are "only" on the hook for one-half of infinity . Like this one.

This is really not a financial question; it is a ruse for restricting participants' access to certain types of health care. The OP's demographic is among the heaviest users, nationally, of the prohibited services so it's potentially coercive to minors, spouses, etc. There are other health systems that try to do that, too, which is why we have laws around these things.

The last thing I'll be doing is declaring bankruptcy.

[marcopolo]

Our Story:

The issue at hand is in the gray area, we've known about this condition before we signed up for the cost sharing ministry however the doctors didn't think it would require surgical intervention


I'm happy to answer any questions and if there is interest I'll update this thread as this ordeal unfolds.

Curious, did you disclose the pre-existing condition when you applied, or did not bother since you did not think it would require any serious treatment?

[SmallCityDave]

In general these plans are well regarded by those actually on the plans but they are severely bashed on BH. But you know what has repeated threads of posters getting the shaft? By their insurance companies refusing to pay claims. Time after time. So spare me the " insurance is government regulated " superior attitude. I have insurance thru my employer but if I didn't I would have no qualms to look at these type of plans.

My intent was to share our experience (good or bad) I don't know how it will turn out but I couldn't be happier with our plan.

I'm glad I didn't check here before we became members...

[willthrill81]

In general these plans are well regarded by those actually on the plans but they are severely bashed on BH. But you know what has repeated threads of posters getting the shaft? By their insurance companies refusing to pay claims. Time after time. So spare me the " insurance is government regulated " superior attitude. I have insurance thru my employer but if I didn't I would have no qualms to look at these type of plans.

I entirely agree. The idea that regulated insurance is great and everything else must automatically be bad is just false.

In general these plans are well regarded by those actually on the plans but they are severely bashed on BH. But you know what has repeated threads of posters getting the shaft? By their insurance companies refusing to pay claims. Time after time. So spare me the " insurance is government regulated " superior attitude. I have insurance thru my employer but if I didn't I would have no qualms to look at these type of plans.

My intent was to share our experience (good or bad) I don't know how it will turn out but I couldn't be happier with our plan.

I'm glad I didn't check here before we became members...

As a group, BHs are great at some things, but they are definitely less than great at other things. In general, anything new or different in finance = bad.