The plans require members to ask for charitable treatment before submitting bills.

A new report has provided the first nationwide tally of Americans who rely on shared health care plans — arrangements through which people agree to pay each other’s medical bills — and the number is higher than previously realized.

The Colorado Division of Insurance report found that more than 1.7 million Americans rely on shared plans, and that many of the plans require members to seek charitable assistance before submitting bills.

The total number of members is probably even higher. The state agency collected data from 16 sharing plans across the United States, but identified five other plans that weren’t reporting their data.

“These plans cover more people than we previously knew,” said JoAnn Volk, co-director of the Center on Health Insurance Reforms at Georgetown University.

Under the agreements, members, who usually share some religious beliefs, agree to send money each month to cover other members’ health care expenses. At least 11 of the sharing plans that reported data operated or advertised plans in all 50 states in 2021.

Sharing plans do not guarantee payment for health services and are not held to the same standards and consumer protections as health insurance plans. Sharing plans aren’t required to cover pre-existing conditions or provide the minimum health benefits mandated by the Affordable Care Act. And unlike health insurance, sharing plans may impose annual or lifetime limits on payments. A single catastrophic health event can easily exceed the limits of a sharing plan.

In Colorado, at least 67,000 people were members of sharing plans in 2021, representing about 1 in 4 Colorados who self-purchased health coverage. That rate concerns Kate Harris, a chief deputy commissioner of the Colorado insurance division, who said she regularly receives complaints from share plan enrollees.

“What we hear from consumers is that when they buy one of these, they think there is some guarantee of coverage, for the most part, despite the disclaimers on many of the organizations’ websites,” Harris said.

The Colorado report found that health sharing agreements often require their members to seek charitable care or assistance from providers, governments or consumer support organizations before submitting requests to share. Those costs are then shifted to other public or private health plans.

Katy Talento, executive director of the Alliance of Health Care Sharing Ministries, which represents five of the largest and longest-running sharing plans in the country, said sharing ministries encourage members to act like the uninsured they are. Those requirements for seeking charitable assistance reflect a desire to be good stewards of their members’ money, Talento said.

“Think of it like a soup kitchen,” he said.

Fourteen share plans reported Colorado members filed a total of $362 million in health care bills in 2021, and nearly $132 million of those requests were approved. The remainder, executives of the sharing plan told the division, reflected duplicate bills, ineligible charges, negotiated discounts and members’ agreed share of medical expenses.

“It’s not like every complaint line on a health care sharing request is going to be eligible for sharing,” Talento said. “They have to present the whole bill. They can’t just take a piece out of it.

But consumer complaints to the Division of Insurance and consumer assistance programs, such as the Colorado Consumer Health Initiative, show members don’t always realize what sharing plans will cover.

“We’ve seen firsthand the risks people face when they sign up for these deals without recognizing the extent of risk they’re taking on their health care costs,” said Isabel Cruz, director of policy for the initiative.

Talent took issue with the notion that members don’t know the parameters of their sharing plans.

“This is just suggesting that our members are stupid,” he said. “Is it likely that somehow our people are about to blindly jump at something?”

Theresa Brilli, a small business owner in Longmont, Colorado, said she and her partner signed up for a directed primary care plan in 2017 that covered primary care visits for $179 a month. Directed primary care plans are payment arrangements between patients and providers to receive health care services without insurance billing. The plan had an agreement with Liberty HealthShare, a Canton, Ohio-based sharing plan with more than 131,000 members nationwide, to cover additional services such as preventive screenings, emergency room care, and hospitalizations for $349 a month with a deductible of $1,000. Rates increased to $499 a month, with a $1,750 deductible, in 2020, Brilli said.

But Brilli said getting the payments was a big hassle.

“It took four to eight months to get paid back,” he said. “It’s been a struggle, every count.”

When she heard about increased subsidies for ACA Market plans in 2022, she decided it wasn’t worth it anymore and switched to a Kaiser Permanente plan for $397 a month.

“I will never go back to Liberty Health or a shared health care plan,” she said. “I didn’t agree with the whole ministry thing. They made you sign that you believed in God, which was like, ‘Whoa, I guess that’s what I have to do to get my health insurance.’”

Laura Murray, 49, of Aurora, Colorado, said she signed up for a Liberty HealthShare plan in 2017 as a cheaper alternative to her husband’s employer-based plan.

“We kind of felt like we were cutting out the middleman, and it was kind of a deal to help your neighbor,” he said.

But when she got pregnant unexpectedly, she had trouble getting her health bills paid. Initially, she Liberty paid only a portion of the bill, and her invoices were sent to a collection agency. It was only through multiple calls that she learned she needed to send invoices to a third party that she would negotiate with the vendors.

“It took years to clarify,” he said.

Timothy Bryan, Liberty’s vice president of marketing and communications, disputed many of the details of Brilli’s account and attributed part of the delay in payment to his “failure to submit the required supporting documentation.” Murray’s payments, he said, were delayed for more than 10 months because he failed to provide the required pre-notification.

Mike Quinlan, 42, of Denver, turned to a health sharing ministry in 2014 after the birth of his first child cost him more than $17,000 out of pocket, as well as nearly $24,000 in premiums that year, under an employer-sponsored health plan. He said the births of his three youngest children were fully covered by Samaritan Ministries International, a Peoria, Ill.-based sharing plan with 359,000 members, to which he contributes $600 a month. When he incurs big health care bills, he receives a slew of $600 checks from other members, he said.

Every year Quinlan declares that he is a Christian and identifies the church he attends.

“This is a group of like-minded people who have voluntarily said that we will trust each other to cover each other’s healthcare costs,” she said.

The rules differ from floor to floor. Some sharing plans require members to commit to Christian principles, and some exclude payment for births out of wedlock or health problems resulting from drug use. Many sharing plans exclude coverage of contraception, mental health services and abortion, often without exceptions for rape or mother’s safety.

Regulators in Colorado and other states have also expressed concern that health sharing agreements are paying brokers much higher fees to sign up members than health plans. This could create financial incentives to push sharing plans on health insurance without properly educating consumers about the differences.

In 2019, Covered California, the Golden State’s ACA market, instituted a requirement that its certified agents who sell both sharing plans and health insurance provide consumers with a list of information about sharing plans and show them benefits they might receive for the purchase of traditional health insurance coverage.

“It’s really important that consumers understand what these deals are and what they aren’t,” said Jessica Altman, executive director of Covered California.

Harris said the Colorado Division of Insurance is investigating multiple health sharing arrangements based on consumer complaints, but declined to name them.

Colorado officials are also concerned that health sharing arrangements could primarily appeal to people who don’t expect to use many health services. This could increase the proportion of sicker and more expensive patients in traditional health insurance plans, driving up premiums.

Harris said many consumers can get a health plan for less than a sharing plan, especially with increased federal and state subsidies put in place in recent years. State officials are also working to educate consumers about the financial risks associated with health sharing deals, some of which have failed in recent years.

“It might look cheaper on the surface, month-to-month,” Harris said. “But if they really need their costs covered, there’s a real risk they might not be.”

KFF Health News is a national newsroom that produces in-depth journalism on health issues and is a major operating program of KFF, an independent source of research, survey and health policy journalism. Find out more about KFF.

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