By Bram Sable-Smith and Kaiser Health News -
NBC News
It took Kelly Macauley nearly a year to realize that the health plan she purchased while looking for insurance coverage last October was not, in fact, insurance.
Red flags certainly appeared along the way, but when she called to complain, she said, she was met with explanations that seemed quite reasonable and continued to make her $700 monthly payments.
Macauley said he was assured that
his medical bills weren't being paid because the hospital had filed them incorrectly
, and that Jericho Share, the nonprofit organization that sent him a membership card that read "THIS IS NOT INSURANCE ", was just the underwriter of his policy, not the real insurer.
Experts recommend getting as much information as possible before purchasing health insurance.
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The woman also had not received a policy welcome packet because, she was told, the company was saving paper to benefit customers with that cut.
This summer, the 62-year-old retired teacher, who recently moved from Philadelphia to South Carolina, learned that her plan had only paid $120 of her hip replacement bill from last year, leaving her
more than $40,000.
Macauley said that when he purchased the health insurance, he had been assured that the procedure would be covered.
But it turns out that the plan he bought wasn't insurance at all, but part of something called a shared care program.
These programs are an alternative to health insurance in which
members agree to share medical expenses.
They are often based on trust and can be cheaper than traditional insurance, although they do not necessarily cover their members' medical bills, according to a report by the Commonwealth Fund, a private foundation that promotes access to better health systems.
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"This was never mentioned to me," Macauley said.
"Honestly, I thought I was buying legitimate health insurance."
Starting Nov. 1,
millions of Americans will buy health insurance by 2023
in a period known as "open enrollment."
Looking for legitimate health plans
Through the federal and state insurance marketplaces, consumers can search for health insurance plans that comply with the Affordable Care Act (ACA) and find out if they qualify for financial help.
But experts warn that the rush to buy coverage also presents an opportunity for those selling alternative products, such as short-term health plans and shared health programs, which are often cheaper than comprehensive coverage but offer far less. protections.
Although these alternatives are legal
, experts warn that misleading marketing can lure consumers looking for comprehensive coverage to purchase health plans that exclude pre-existing condition protection and leave patients exposed to large medical bills.
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"This is a risky time for consumers shopping for insurance, as they may want to steer them down the wrong path," said JoAnn Volk, co-director of the Center for Health Insurance Reform at Georgetown University.
“Those who commit fraud have no limits”
Volk mentioned these signs as potential red flags: If the person selling you a plan starts asking about your health history,
refuses to send you information about the plan
, or promises to provide that information only after you give him your payment information.
According to a 2021 report on deceptive marketing practices, co-authored by Volk, a marketer incorrectly cited the Health Insurance Portability and Accountability Act (HIPAA), which protects patient privacy, as a reason for do not share information about the health plan.
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"It's made up stuff," Volk said.
"Those who commit fraud have no limits."
In a statement to Kaiser Health News (KHN), Jericho Share spokesman Mark Hubbard said the organization could not discuss Macauley's case without his prior written approval, but that it does not tolerate any misrepresentation or misconduct. unethical on the part of its programs.
Across the country, lawmakers and regulators are watching how health care plans are sold.
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The chairman of the Senate Finance Committee, Oregon Democrat Ron Wyden, is investigating complaints about how Medicare Advantage plans are being marketed.
And in May, the Centers for Medicare and Medicaid Insurance Services noted that
complaints
about the marketing practices of Medicare Advantage and Medicare prescription drug benefit plans
rose
from 15,497 in 2020, to at least 39,617 in 2021.
More and more scams
"Healthcare-related scams have increased exponentially," said Delaware Insurance Commissioner Trinidad Navarro, who also chairs the National Association of Insurance Commissioners' anti-fraud task force.
There are several factors that cause this increase, according to Navarro.
Rising health care prices can drive up the cost of regulated health plans, such as those that comply with the ACA.
Rising costs are pushing more Americans to look for cheaper alternatives
that typically don't offer as much coverage and can confuse consumers.
Those types of plans proliferated under the administration of former President Donald Trump, Navarro said.
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"I don't want to sound political," said Navarro, an elected Democrat, "but the previous administration was really pushing the weak plans and alternatives to the ACA, and I don't think they necessarily understood the fraud that was associated with these plans."
Finally, Navarro said that since states are the primary regulators of insurance, cracking down
on health care scams can be like playing roulette
: when one state takes action, fraudsters move to another to keep operating.
To combat that tactic, Navarro said, insurance regulators across the country have created what he described as a "confluence page" to share information about fraudsters with each other.
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Navarro said regulators are talking about creating a public inquiry tool to seek complaints against health insurance brokers, similar to the BrokerCheck tool created by the Financial Industry Regulatory Authority to monitor stockbrokers.
For now, Navarro suggests working with health care navigators, which help consumers sign up for plans through the official health insurance marketplace, healthcare.gov.
Fight against sellers of "fake health plans"
Additionally, regulators have taken legal action against deceptive health insurance sales tactics.
In August, the Federal Trade Commission obtained $100 million in refunds for consumers it said were "scammed" with phony health plans.
Last year, the Massachusetts attorney general obtained $515,000 in consumer relief from an insurance company accused of deceptive sales practices.
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Court filings from October indicate that California's attorney general is investigating Jericho Share, the health care ministry that Kelly Macauley said she
unknowingly purchased a plan from,
to see if it complies with state law.
Jericho Share spokesman Hubbard said the organization is "responding appropriately" to the attorney general's investigation.
Macauley contacted KHN after reading an investigation in June of consumers who said they thought they were buying insurance only to find out they had been sold other plans where they were supposed to share the cost of health care.
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Hubbard said that since that story was published, Jericho Share automatically provides 72-hour refunds to new consumers who request it within 30 days of signing up, no longer allows "external marketing of sign-ups," and has added a member guide and a section on their website stating that Jericho Share is a shared care program.
The company responded to Macauley's criticism on the Better Business Bureau website, asking for more information about his case.
She said that she had already provided the information they asked for, but she never received a response.
After Macauley unsuccessfully tried to cancel his
Jericho Share plan with the company directly, he said, he called his credit card company not to approve any more charges from the company.
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When he described his situation, Macauley said, the credit card representative told him, "This is fraud," and offered to try to get Macauley to recover all of his previous payments.
Even if that effort is successful, Macauley still faces the debt of tens of thousands of dollars in medical expenses he unknowingly incurred while uninsured.
Macauley is looking for health insurance and plans to choose a company he has already heard about.
"
Whatever it takes
," Macauley said, "I just want to be sure that I have real insurance."
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with Policy Analysis and Polling, KHN is one of the three main operational programs of KFF (Kaiser Family Foundation). KFF is a nonprofit organization that provides information on health issues to the nation.
