Altrua HealthShare

HCSM
Health Care Sharing Ministry (under ACA)
Altrua members
exempt from federal penalty imposed on those who don’t have health insurance
Altrua members
nationwide faith-based membership, uphold Statement of Standards, share in each other’s medical needs
Altrua is NOT health insurance
alternative to rising healthcare costs
ACA enrollment is limited
failure can result in being locked out of the ACA
Statement of Standards
not tied to one specific faith, open to all walks of faith, faith based, Biblical standards
Solicitors need to be comfortable and willing to embrace same set of standards (Statement of Standards)
to professionally, ethically and honorably represent Altrua
Faith-based alternative solution
problem of rising health care costs, expensive policies
no longer only option of
reduced coverage, higher deducibles
sharing ministries have been available for
thirty years; Altrua since 1999; Randall Sluder 2005; operated by Crown HealthShare Administrators, Inc.
What separates Altrua from other HCSM offerings?
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
Statement of Standards.
Do you:
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.
Statement of Standards note
Some individuals may NOT be eligible or have a membership limitation due to certain past medical history or present medical conditions.
By operating with a statement of standards Altrua
expands its potential member base due to the fact that Altrua is not tied to one specific faith.
HCSM programs are
NOT health insurance
Members are considered by the medical profession
to be self-pay patients
Shared costs typically are lower negotiated costs for services
than are charged to health insurance companies
Members do not participate in subsidizing certain lifestyle choices others make
which adds to the rising costs of traditional health insurance
Members commit to:
healthy and honorable lifestyles according to God’s principles
Medical needs are shared
needs reimbursed out of escrowed contributions
There is no guarantee or promise that
eligible needs by the membership??
What happens to eligible medical needs the membership is unable to share?
They will remain the financial responsibility of the member should the program cease to operate.
What is the Altrua opportunity?
like minded members to care for one another in a time of need
Altrua is not a legally binding agreement to reimburse any member for medical needs??
not insurance
When are medical needs shared?
Medical needs will be reimbursed from the escrow from all member contributions.
“How it works” for the member.
The member shares (pays monthly premium in Insurance terms, but this is not Insurance):
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
EOB: Explanation of Benefits equals
EOS: Explanation of Sharing
Member medical needs are processed according to
Member Guidelines and the membership type selected by member
“How it works” for the member who is in need of medical help:
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
“you just want healthy people, don’t want to pay claims”
Wrong! We want to negotiate the price.
1st and 2nd MRA (deductible in Insurance world)
Member Responsibility Account (deductible)
Affiliated provider
PHCS network www. multiplan.com
Non-affiliated provider
not in PHCS network, office visit is 50% of office visit
How many office visits per year is the member allowed?
six per calendar year
Gold and Silver Office visits
included up to $300 per visit with $35 MRA (deducible) for PHCS affiliated network; Bronze NA
Gold and Silver Maternity
$4,000 max normal delivery; $6,000 max for medically necessary C-section; Bronze NA
Prescription drugs
only for eligible needs, 3 RX per month/member
What is your best prescription drugs strategy if you have over 4 drugs?
get the most expensive ones filled
What are the types of membership?
1. Standard: Gold, Silver, Bronze
2. Advantage: Gold, Silver, Bronze
What if your family is larger than 5?
Add $50 for each additional family member
How do you calculate age if the husband and wife are both participating?
The “head of household” is based on the older spouse’s age.
How do you calculate if the head of household is 65 or over?
contribution is base on younger spouse’s age.
What is the office visit MRA (deductible).
Office visit MRA does not apply to 65+ Medicare plans.
Altrua Advantage plan is liken to
Catastrophic plans
Is maternity covered in the Bronze plan?
not available
What is the annual maximum limit on the Bronze plan?
$50,000
What happens when it is discovered that a prospective member or active member did not provide complete and accurate medical history or information?
Membership can be declined, a retroactive membership limitation can be implemented, active membership can be retroactively declined.
A membership limitation can be removed when?
with appropriate medical evidence… Have you ever heard of that happening with traditional health insurance?
Fraud results in
Cancellation… just like in traditional insurance
Membership Qualifications. Financial Participation.
Application fee $100,
Annual membership contribution: $100??
Altrua donation $25 currently??
Monthly membership contribution
Membership Qualifications – What happens if there is a missed contribution?
results in that month’s eligible needs not being shared
Membership Qualifications – What is the consequences of an inactive membership?
can be reinstated when past due contributions are made within 90 days – same as ACA plans.
What are eligible needs?
only needs incurred on or after the membership effective date.
Where are the needs filed?
Needs must be filed on appropriate appropriate forms. Medical records may also be required from providers; needs forms are on website
What about needs arising from a defined and disclosed listing?
not eligible
Appeals and grievance process
Established process.
Affiliated provider
PHCS network
Contributor
person named as head of household
Escrow instructions
Contained on the membership application on page 6.
It outlines the order in which contributions may be shared
by AHS.
Full-time service volunteer??
person eligible as a dependent covered household member. Who, without receiving a salary, contributes services for a religious organization?
Guidelines
an outline for eligible needs in which contributions are shared in accordance with the membership escrow instructions
Member
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
Altrua HealthShare
501c3 non profit.
Bronze office visits
NA
Bronze maternity
NA
Application Date
the date Altrua receives a completed application
Guidelines
outline for eligible medical needs in which contributions are shared in accordance with the membership escrow instructions.
Membership limitation
specified medical condition for which medical needs arising from or associated with the condition are NOT eligible for sharing.
What is an associated condition?
An associated condition is one that is caused directly and primarily by the medical condition that is specifically not eligible
MRA
the amounts of an eligible need which are first paid by the member then eligible for sharing by the plan
Monthly contributions
Monetary contributions excluding the annual membership contribution voluntarily given to AHS to hold as an escrow agent
Monthly contributions
are disbursed according to the membership escrow instructions.
Needs
charges or expenses for medical services from a licensed medical practitioner or facility arising from an illness or accident for each member
UCR – Usual, Customary and Reasonable
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
Perks of membership
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
How is the weight verified?
clinic?
Applicants whose weight exceeds the $45 increase limit
Not eligible for membership
What if applicant loses weight?
Must maintain weight within guidelines for 90 days.
AHS offers a program to help
prospective applicants with meeting and maintaining the required height/ weight guidelines.
AHS Application process.
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.
AHS Application process.
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
Ethics and Compliance
Ethics and Compliance
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
Ethics and Compliance
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
Representatives will not
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
Membership with Limitation means:
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.
If the application is all is in order by the 25th of the month then
membership is the 1st of the next month.
Membership Qualifications
Review automatic decline conditions
Review Height – weight guidelines
When it is discovered that a prospective member or active member did not provide complete and accurate medical history
Membership can be declined.
A retroactive membership limitation can be implemented requiring a required additional contribution each month.
Commission
If a loss ratio is at or above 75%, Altrua shall have the right to terminate the agreement or reduce commission rate
Representatives may
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
History of Health Care Sharing Ministries HCSM
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
How it works when the Member has a Medical need or crisis:
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
CO-OPS VERSUS HEALTH CARE SHARING

Health Care Sharing Ministries are nothing like CO-OPS.

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.
Dependents Qualifications
Children under the age of 20, spouse living under the same roof (no estranged spouses)
Dependents Qualifications Newborn
Must notify AHS within 30 days of birth
Dependents Qualifications
Children 20-24 with appropriate documentation proof and 90 days beyond 25th birthday with proof of an ongoing need
Dependents Qualifications
Full time student -12 hours pre semester and a full-time volunteer (missionary).
Dependents Qualifications
older dependents due to medical conditions verified by a qualified health professional
Dependents doing drugs
Violation, off the plan
Employer must offer
choices to the employee
pre-existing conditions
LIMITED for the first 12 months of membership
Not eligible
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.
not eligible
DME, untimely filing of needs – 9 months for active members, psychiatric counseling, metal health, autism, substance abuse, ADD, hyperactivity,
Not eligible
second surgeries on previously eligible surgical need unless, telephone consultations, diagnostic testing within first year of effective date
Lifetime limit
$1,000,000
annual limit Bronze
$50,000
pre-payment of services
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.
recreational limit
$5000 per need UNLESS additional monthly contribution
Organ transplant limit
$150,000 maximum
Home infusion therapy limit
up to a maximum of 50% of allowed charges
If the member does not cooperate fully in determining if the need is discountable?
the need will not be eligible for sharing
pre-notification
non-emergency surgery, procedure of test: the member must have the procedures pre-authorized as medically necessary
ER visits, emergency surgery
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.
cancer
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.
cancer, members over 40
members age 40 and older are required to receive appropriate screening test bi-annually; mammograms, gynecological, PSA. Failure will render future needs ineligible.
sharing limits maternity
10 consecutive months in a combined membership
If a member elects to use a mid-wife
mid-wife must be tested for group B strep prior to delivery.
Complications of pregnancy
not subject to maternity sharing limits
newborn will be eligible to participate
30 days after delivery
once pregnant the member must
notify Altrua to determine eligibility criteria have been met. The member will have the choice of 2 reimbursement options.
Appeals
Most situations can be resolved simply by calling a member services representative
refusal of treatment
may mean future medical needs will not be eligible for sharing
groups less than 49
small group in Texas
groups over 50
large group in Texas