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HCSM

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Health Care Sharing Ministry (under ACA)

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Altrua members

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exempt from federal penalty imposed on those who don't have health insurance

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Altrua members

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nationwide faith-based membership, uphold Statement of Standards, share in each other's medical needs

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Altrua is NOT health insurance

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alternative to rising healthcare costs

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ACA enrollment is limited

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failure can result in being locked out of the ACA

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Statement of Standards

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not tied to one specific faith, open to all walks of faith, faith based, Biblical standards

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Solicitors need to be comfortable and willing to embrace same set of standards (Statement of Standards)

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to professionally, ethically and honorably represent Altrua

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Faith-based alternative solution

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problem of rising health care costs, expensive policies

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no longer only option of

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reduced coverage, higher deducibles

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sharing ministries have been available for

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thirty years; Altrua since 1999; Randall Sluder 2005; operated by Crown HealthShare Administrators, Inc.

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What separates Altrua from other HCSM offerings?

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Statement of Standards not Statement of Faith or Ethics, not tied to one faith, available nationwide, needs paid from Escrow Account (not individually shared member to member), complete Health and wellness program

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Statement of Standards. Do you:

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A. Abstain from sexual relations outside the bond of marriage between a man and a woman B. Believe in caring for one another C. Clean Healthy lifestyle D. Drugs - affirm you have refrained from tobacco, illegal drugs for the past 12 months.

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Statement of Standards note

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Some individuals may NOT be eligible or have a membership limitation due to certain past medical history or present medical conditions.

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By operating with a statement of standards Altrua

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expands its potential member base due to the fact that Altrua is not tied to one specific faith.

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HCSM programs are

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NOT health insurance

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Members are considered by the medical profession

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to be self-pay patients

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Shared costs typically are lower negotiated costs for services

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than are charged to health insurance companies

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Members do not participate in subsidizing certain lifestyle choices others make

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which adds to the rising costs of traditional health insurance

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Members commit to:

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healthy and honorable lifestyles according to God's principles

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Medical needs are shared

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needs reimbursed out of escrowed contributions

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There is no guarantee or promise that

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eligible needs by the membership??

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What happens to eligible medical needs the membership is unable to share?

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They will remain the financial responsibility of the member should the program cease to operate.

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What is the Altrua opportunity?

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like minded members to care for one another in a time of need

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Altrua is not a legally binding agreement to reimburse any member for medical needs??

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not insurance

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When are medical needs shared?

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Medical needs will be reimbursed from the escrow from all member contributions.

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"How it works" for the member. The member shares (pays monthly premium in Insurance terms, but this is not Insurance):

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1. The member receives contribution request (a bill or premium invoice in insurance terms) 2. AHS receives contribution (premium) 3. The members may submit additional contributions 4. AHS deposits contributions into AHS escrow 5. AHS transfers monthly operating expenses from escrow to operating account 6. AHS process needs according to guidelines 7. AHS issues check to provider from escrow

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EOB: Explanation of Benefits equals

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EOS: Explanation of Sharing

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Member medical needs are processed according to

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Member Guidelines and the membership type selected by member

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"How it works" for the member who is in need of medical help:

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member has medical need and selects provider or facility, member presents AHS ID card, provider calls AHS for pre-authorization on any non-emergency testing, procedure or surgery, member notifies AHS of any ER visit or hospital admit, provider sends claim to AHS, member receives not an EOB but an EOS, AHS issues check to provider

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"you just want healthy people, don't want to pay claims"

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Wrong! We want to negotiate the price.

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1st and 2nd MRA (deductible in Insurance world)

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Member Responsibility Account (deductible)

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Affiliated provider

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PHCS network www. multiplan.com

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Non-affiliated provider

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not in PHCS network, office visit is 50% of office visit

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How many office visits per year is the member allowed?

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six per calendar year

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Gold and Silver Office visits

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included up to $300 per visit with $35 MRA (deducible) for PHCS affiliated network; Bronze NA

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Gold and Silver Maternity

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$4,000 max normal delivery; $6,000 max for medically necessary C-section; Bronze NA

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Prescription drugs

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only for eligible needs, 3 RX per month/member

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What is your best prescription drugs strategy if you have over 4 drugs?

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get the most expensive ones filled

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What are the types of membership?

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1. Standard: Gold, Silver, Bronze 2. Advantage: Gold, Silver, Bronze

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What if your family is larger than 5?

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Add $50 for each additional family member

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How do you calculate age if the husband and wife are both participating?

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The "head of household" is based on the older spouse's age.

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How do you calculate if the head of household is 65 or over?

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contribution is base on younger spouse's age.

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What is the office visit MRA (deductible).

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Office visit MRA does not apply to 65+ Medicare plans.

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Altrua Advantage plan is liken to

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Catastrophic plans

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Is maternity covered in the Bronze plan?

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not available

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What is the annual maximum limit on the Bronze plan?

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$50,000

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What happens when it is discovered that a prospective member or active member did not provide complete and accurate medical history or information?

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Membership can be declined, a retroactive membership limitation can be implemented, active membership can be retroactively declined.

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A membership limitation can be removed when?

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with appropriate medical evidence... Have you ever heard of that happening with traditional health insurance?

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Fraud results in

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Cancellation... just like in traditional insurance

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Membership Qualifications. Financial Participation.

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Application fee $100, Annual membership contribution: $100?? Altrua donation $25 currently?? Monthly membership contribution

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Membership Qualifications - What happens if there is a missed contribution?

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results in that month's eligible needs not being shared

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Membership Qualifications - What is the consequences of an inactive membership?

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can be reinstated when past due contributions are made within 90 days - same as ACA plans.

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What are eligible needs?

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only needs incurred on or after the membership effective date.

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Where are the needs filed?

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Needs must be filed on appropriate appropriate forms. Medical records may also be required from providers; needs forms are on website

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What about needs arising from a defined and disclosed listing?

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not eligible

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Appeals and grievance process

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Established process.

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Affiliated provider

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PHCS network

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Contributor

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person named as head of household

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Escrow instructions

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Contained on the membership application on page 6. It outlines the order in which contributions may be shared by AHS.

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Full-time service volunteer??

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person eligible as a dependent covered household member. Who, without receiving a salary, contributes services for a religious organization?

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Guidelines

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an outline for eligible needs in which contributions are shared in accordance with the membership escrow instructions

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Member

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person or persons who qualify to receive voluntary sharing of contributions for eligible medical needs according to the membership escrow instructions, guidelines and membership type

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Altrua HealthShare

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501c3 non profit.

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Bronze office visits

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NA

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Bronze maternity

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NA

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Application Date

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the date Altrua receives a completed application

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Guidelines

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outline for eligible medical needs in which contributions are shared in accordance with the membership escrow instructions.

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Membership limitation

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specified medical condition for which medical needs arising from or associated with the condition are NOT eligible for sharing.

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What is an associated condition?

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An associated condition is one that is caused directly and primarily by the medical condition that is specifically not eligible

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MRA

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the amounts of an eligible need which are first paid by the member then eligible for sharing by the plan

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Monthly contributions

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Monetary contributions excluding the annual membership contribution voluntarily given to AHS to hold as an escrow agent

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Monthly contributions

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are disbursed according to the membership escrow instructions.

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Needs

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charges or expenses for medical services from a licensed medical practitioner or facility arising from an illness or accident for each member

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UCR - Usual, Customary and Reasonable

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the lesser of the actual charge or the charge most other providers would make, as determined by Altrua HealthShare as baseline to pay out of network providers

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Perks of membership

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Caring people who help others. Members are exempt from the Affordable Care Act $1 Million lifetime benefit per family member Help A Friend Referral Credit Health and Wellness Program Yearly Healthy Lifestyle Credit

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How is the weight verified?

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clinic?

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Applicants whose weight exceeds the $45 increase limit

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Not eligible for membership

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What if applicant loses weight?

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Must maintain weight within guidelines for 90 days.

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AHS offers a program to help

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prospective applicants with meeting and maintaining the required height/ weight guidelines.

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AHS Application process.

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1. Fill Membership application and Medical Questionnaires. 2. Applicant submits application along with fees. 3. Once AHS receives application and fees, new applicant will be contacted by phone or email 4. New apps will go through the approval process pending tests. 5. If the new applicant decides to withdraw their app they must contact AHS directly.

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AHS Application process.

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6. If the new applicant has membership limitations that apply, new applicant must sign the membership limitations doc prior to membership being effective. 7. If new applicant accepts terms of membership, new applicant will be contacted by phone or email advising them of their acceptance and effective date. 8. A new member pack will be mailed to the dress of the New Member. 9. Membership ID cards will be mailed separately to New Member once completed. 10. For any questions regarding a new membership call 888-244-3839

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Ethics and Compliance

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1. Representatives should endeavor to place the public interest above their own. 2. Reps should seek to improve professional knowledge 3. Reps should obey all laws 4. Reps should should be diligent in the performance of their occupational duties and strive to improve functioning of the HCSM 5. Reps should raise ethical standards 6. Reps should maintain honorable relationships with clients

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Ethics and Compliance

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7. Reps should assist in improving public understanding of HCSM 8. Reps should provide considerate and courteous service as well as respect personal privacy and dignity of prospective members. 9. Reps should ensure application process is accurate 10. Reps must submit full payments and never finance contributions 11. Reps must ensure prospective members receive appropriate documentation as defined in guidelines 12. Reps must fully comply with Membership Guidelines to ensure eligibility

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Representatives will not

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call the program insurance not use insurance terminology never backdate an application not say guaranteed issue will not say eligible needs will always be reimbursed

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Membership with Limitation means:

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Prospective member has a specific medial condition which are not eligible for sharing. The prospective member has the right to decline the membership with limitation. $100 application fee will be refunded but $25 ministry donation will not be refunded.

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If the application is all is in order by the 25th of the month then

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membership is the 1st of the next month.

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Membership Qualifications

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Review automatic decline conditions Review Height - weight guidelines

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When it is discovered that a prospective member or active member did not provide complete and accurate medical history

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Membership can be declined. A retroactive membership limitation can be implemented requiring a required additional contribution each month.

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Commission

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If a loss ratio is at or above 75%, Altrua shall have the right to terminate the agreement or reduce commission rate

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Representatives may

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Prospect for health conscious members that adhere to a healthy standard of living Faith based individuals and groups - private schools, non-profits, churches Engage in approved marketing campaigns

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History of Health Care Sharing Ministries HCSM

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Bearing one another's burdens was the hallmark of our nations beginnings HCSM born in early 1980's HCSM has grown and thrived as an alternative to traditional insurance ever rising costs and skyrocketing health care costs 400,000 + members

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How it works when the Member has a Medical need or crisis:

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1. Member selects a provider or facility 2. Member presents AHS ID card 3. Provider calls AHS provider department for pre-authorization on non-emergencies 4. Member or provider notifies AHS of any ER visit or hospital admit 5. Provider sends claim to AHS 6. Member receives EOS (EOB) 7. AHS issues check to provider from escrow account

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CO-OPS VERSUS HEALTH CARE SHARING Health Care Sharing Ministries are nothing like CO-OPS.

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HCSM are not-for-profit, and they are run by their members, but they do not try to act like insurance companies. They don't have a contract to pay benefits. The members of the Ministry help to share the medical expenses of other members, but each member is ultimately responsible for his or her own expenses. Preventative services are not shared. The Ministry doesn't take out loans, it doesn't use actuaries, it doesn't do underwriting, and it is not subject to insurance regulations. They are, however, subject to the same regulations as all other charities.

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Dependents Qualifications

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Children under the age of 20, spouse living under the same roof (no estranged spouses)

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Dependents Qualifications Newborn

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Must notify AHS within 30 days of birth

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Dependents Qualifications

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Children 20-24 with appropriate documentation proof and 90 days beyond 25th birthday with proof of an ongoing need

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Dependents Qualifications

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Full time student -12 hours pre semester and a full-time volunteer (missionary).

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Dependents Qualifications

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older dependents due to medical conditions verified by a qualified health professional

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Dependents doing drugs

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Violation, off the plan

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Employer must offer

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choices to the employee

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pre-existing conditions

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LIMITED for the first 12 months of membership

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Not eligible

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Surgery in the first 90 days unless..., abortion unless..., infertility testing, maternity from adultery or fornication, hysterectomy without securing tow independent medical opinions and both must agree.

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not eligible

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DME, untimely filing of needs - 9 months for active members, psychiatric counseling, metal health, autism, substance abuse, ADD, hyperactivity,

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Not eligible

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second surgeries on previously eligible surgical need unless, telephone consultations, diagnostic testing within first year of effective date

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Lifetime limit

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$1,000,000

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annual limit Bronze

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$50,000

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pre-payment of services

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members pre-paying at time of service without providing Altrua the opportunity to discount eligible needs will only have those needs shared at 50%. Pre=authorization is the only exception.

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recreational limit

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$5000 per need UNLESS additional monthly contribution

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Organ transplant limit

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$150,000 maximum

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Home infusion therapy limit

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up to a maximum of 50% of allowed charges

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If the member does not cooperate fully in determining if the need is discountable?

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the need will not be eligible for sharing

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pre-notification

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non-emergency surgery, procedure of test: the member must have the procedures pre-authorized as medically necessary

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ER visits, emergency surgery

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an emergency is defined as treatment that must be rendered to the patient immediately for the alleviation of the sudden onset of an unforeseen illness that if not treated would lead to further disability or death.

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cancer

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the member is required to contact Altrua WITHIN 30 days of the diagnosis. If the member fails at this thee member will be responsible for 50% of the total allowed charges.

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cancer, members over 40

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members age 40 and older are required to receive appropriate screening test bi-annually; mammograms, gynecological, PSA. Failure will render future needs ineligible.

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sharing limits maternity

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10 consecutive months in a combined membership

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If a member elects to use a mid-wife

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mid-wife must be tested for group B strep prior to delivery.

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Complications of pregnancy

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not subject to maternity sharing limits

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newborn will be eligible to participate

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30 days after delivery

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once pregnant the member must

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notify Altrua to determine eligibility criteria have been met. The member will have the choice of 2 reimbursement options.

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Appeals

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Most situations can be resolved simply by calling a member services representative

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refusal of treatment

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may mean future medical needs will not be eligible for sharing

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groups less than 49

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small group in Texas

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groups over 50

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large group in Texas

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