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.