Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Hi, welcome back everybody. So we're pivoting back to H585, and two things I wanted to mention. If you recall, there was section number It was the very last section of this bill, section 13, which was the reinsurance authorization to pursue the thirteen thirty two waiver. That was part of this bill. But if you remember from Jen's letter to appropriations, we're going to strike it out of this bill, and we have now put it in our language in the budget. Okay, so that's where that went to. If anyone thinks that we're not pursuing it, we absolutely are. We're just It seemed like a better place to put it in the budget. Noticed. Okay, we noticed. That language looked familiar to you at all. Second of all, I asked, we've some bills on our walls and we've been talking about in this bill, association health plans, short term limited liability plans, and we've had a bill on our wall, I know this year, which I thought it might be interesting to get some information on H102, which is reporting on healthcare sharing plans and other arrangements. So while we're talking about plans, I've invited DFR to come in and talk about sharing plans as well. So we have

[Mary Block, Deputy Commissioner of Insurance (DFR)]: Mary Block with us. Thank you. For the record, Mary Block, I'm the Deputy Commissioner of Insurance for DFR. So healthcare sharing plans. So you didn't send anything in? I did not send anything in. Healthcare sharing plans are not regulated by DFR. They are not insurance. So, we only see them from the outside, obviously. They are often faith based. For the most part, they are faith based. At the time that the ACA went into effect, there was a very narrow exemption that allowed them to continue to provide, call it, coverage, that did not have to comply with the components of the ACA because they are not insurance. So some differences between a healthcare sharing plan and an insurance policy. A healthcare sharing plan is a member driven entity. Like I said, they are generally faith based, which often means that anyone who signs up is required to file a statement of faith with the organization, is agreeing to conduct their life, according to the tenants of that organization, whatever that may be, because there's various types of faiths that, have created these organizations. They are modeled off of medical sharing, much more loosely built medical sharing arrangements that go way back in religious history. The Church of the Latter day Saints has often supported their members by pooling funds. I know in the Hasidic Jewish community, these things happen. They're loosely based on these long standing religious organizations' support for their members. So you can sign up. It is not ACA compliant. I think it's not insurance. Does not meet the state law, Vermont state law mandates to have insurance coverage. Because they do not have to be ACA compliant, obviously they build their own plan components. So they can have pre existing conditions, for example. There can be exclusions. They generally seem to target more healthier individuals who are looking for baseline coverage of, say, preventive services and then something for catastrophic events that might occur. A lot of times the exclusions or the pre existing conditions line up with the religious tenants of that particular organization. So some of them, for example, can't use drugs, can't smoke, in some no contraception. It all depends on the beliefs of that particular organization. There are some now limited, one in particular that I can think of, that is not purely religious based. But for the most part, do have that connection. A lot of the pre existing condition exclusions are related to chronic conditions oftentimes, and to things you would assume the various religious organizations would not be comfortable with, like abortion or gender affirming care or things like that. Just depends on the organization. Where there have been issues is they are non insurance, which means they can't represent themselves that way. They have to be careful about making sure that it is clear to their members that this is not an insurance policy. Some less than stellar organizations have gotten into trouble as a result of that. There was a very recent actually came out in the last week, New York Department of Insurance sanction against an organization, which we will now be looking into because we now know that they do business in multiple states. Because they were advertising as if they were insurance and misleading her members into thinking it was insurance. We did a cease and desist order in 2019 for another organization that was doing similar things, emails and advertisements and so forth, that made it look like it was an insurance policy as opposed to what it is, which is a sharing plan. So no legal prohibition against it. If somebody wants to be involved or join, they need to go in with their eyes open and understand what's allowed, what's not allowed, what's going to be covered, what's not going to be covered, and what kind of commitments they're making to lifestyle or religious beliefs or whatever that is required by that particular organization in order to be a part of it. One of the other byproducts that can be problematic from a competitive market perspective is people who are members don't have insurance. So when they go for treatment, they rightfully tell a provider they are uninsured. That often qualifies them for discounts, may result in them being treated as uncompensated care from a hospital perspective or so forth. So it sort of skews things because they do that first. Some of the organizations will then negotiate charges on their behalf, some don't. So it just depends on the particular plan. So it sort of does throw off that dynamic a little bit because that compensation that they may get, that coverage that they may get is not sort of a part of the equation with the provider at the point of sale, we'll call it. So

[Alyssa Black (Chair)]: that's the high points. I think I have questions for you that I hope you'll be able to answer. And I'm asking because I don't mean to testify myself, but I spent over twenty five years working in a medical practice. Do members of SharePlans have cards, like an insurance card?

[Mary Block, Deputy Commissioner of Insurance (DFR)]: I think it depends on the plan.

[Alyssa Black (Chair)]: Do you know if some of these sharing plans have agreements with established PPO networks? I don't believe so.

[Mary Block, Deputy Commissioner of Insurance (DFR)]: Not formal agreements, I wouldn't think, but I'm not positive, honestly, because we don't have a lot of line of sight into I think that's actually

[Alyssa Black (Chair)]: what Do you ever receive Does DFR ever receive inquiries?

[Mary Block, Deputy Commissioner of Insurance (DFR)]: Get complaints on occasion, or inquiries from people about, Is this an insurance plan? Or questions like that. So yes, we get them. And we do what we can to facilitate. We can answer the question, Is this an insurance plan? That's obviously an easy question for us to answer. If they have a complaint, we sometimes try to mediate and get them in contact with someone at the plan that can help them resolve their issue. Are any of these plans required to register in the state of Vermont? They're not insurance. They're not insurance. They're not insurance, so we do not regulate them. The only time we regulate them is if they step over the line and start acting like insurance.

[Alyssa Black (Chair)]: And we have no idea how many Vermonters are members of

[Mary Block, Deputy Commissioner of Insurance (DFR)]: No real idea, no. We have an idea oddly only because Colorado has a reporting requirement. They do an annual report. According to their report, the plans that have reported to them identified that 14 of them are operating in the state of Vermont, but we don't know how many people that is. Colorado knows about Vermont? So they ask their, as part of their reporting requirement, they ask them to identify where they're operating. So 14 plans who reported to Colorado identified that they were also operating in Vermont. Also, so that's Yeah. Okay.

[Wendy Critchlow (Member)]: Wendy? I'm having a really hard time understanding. If someone were to go into the hospital and they're this is what they have enrolled in, I know it's not insurance, And they just say, I have no insurance. Yes. Technically They're self pay. Yes. But do they have to? Like, if the insurance company was or not the insurance company, but faith based health care sharing plans.

[Alyssa Black (Chair)]: They're not reimbursing the hospital.

[Mary Block, Deputy Commissioner of Insurance (DFR)]: No. They will bill the person who's self pay, because they're saying, I don't have insurance, I'm gonna pay for myself. So the hospital will bill them, and that person will notify the sharing ministry that they have a claim and fill out whatever forms they got to fill out or whatever they need to do, provide whatever documentation is required. And then the sharing ministry would determine what would be covered and pay that individual member.

[Alyssa Black (Chair)]: Pay the individual member goes to the hospital. Right. Okay. Leslie, the individual have any recourse if the sharing plan declines to pay the bill?

[Mary Block, Deputy Commissioner of Insurance (DFR)]: So not through us, right? Obviously not insurance, they're not regulated by us. I don't know whether they have any fee hours through say the AG's office as a standard. I know I've heard just in conversations with the AG office that they have gotten complaints on occasion about health care sharing ministries. I don't know how prevalent that is. But yeah, you'd have to go that route and the AG's office would have to determine if it was a violation of Consumer Protection

[Alyssa Black (Chair)]: Do you, at DFR, communicate with the AG's office if you get complaints?

[Mary Block, Deputy Commissioner of Insurance (DFR)]: We haven't had any in a while. We do refer complaints to the AG's office that we get that they would handle. So that would be our normal practice for anything that we don't cover.

[Alyssa Black (Chair)]: I have Brian. Brian's on the first. Yep, you're fine.

[Brian Cina (Member)]: Yep. Go first if you want. No, I don't. No, I didn't see your hand. So, it sounds like there's not a lot of oversight of these plans. I'm wondering, is it possible that a person could receive a service from a hospital and then get a bill, submit it to their healthcare sharing plan, thank you be partially reimbursed, but then tell the hospital that they can't afford it and claim medical debt, and the hospital excuses their debt, and they just pocket the money from the healthcare sharing plan because no one's watching how it all

[Mary Block, Deputy Commissioner of Insurance (DFR)]: is flowing? I honestly can't answer that question. I don't know.

[Brian Cina (Member)]: You don't know because there's no one watching it.

[Mary Block, Deputy Commissioner of Insurance (DFR)]: Yeah, there is no organization that would be watching.

[Brian Cina (Member)]: There's nothing to prevent that from happening that we're aware of. Do we know healthcare sharing plans ask for evidence that the person paid the bill with the money they gave them, like a receipt? I have no idea. Because we don't regulate it. Thank you. Yes, Allen, I've and then I got We have no jurisdiction whatsoever.

[Mary Block, Deputy Commissioner of Insurance (DFR)]: The Department of Financial Regulation doesn't. I don't know whether it would fall under consumer protection or not. So we have to ask the AGO's office if it the AGO's office if it fell under that. Karen?

[Alyssa Black (Chair)]: It's on the patient to pay the doctor or the hospital. And then you either make up a payment plan or you pay them out of your pocket and then you send him a bill to whatever shared system you're in, and then they send you the money.

[Brian Cina (Member)]: I know you're not the witness, but you do have experience with them. So I think it's okay to is it okay if I ask you a question?

[Alyssa Black (Chair)]: Fine with me.

[Brian Cina (Member)]: Okay. Just to clarify what you said, are you aware of healthcare sharing plans asking for a receipt versus a bill?

[Alyssa Black (Chair)]: You have to send in their codes, your codes.

[Brian Cina (Member)]: But not a receipt that you paid the hospital? No. Okay.

[Alyssa Black (Chair)]: No, because you set up the payment to the hospital. And what good is it for you to get money and pocket it and then, and not pay your bills?

[Brian Cina (Member)]: Well, the hospital might forgive the debt and then you just make money off you. That's what I'm, that could've.

[Alyssa Black (Chair)]: But like she said, most of these are faith based.

[Brian Cina (Member)]: Oh, so they have to be violating their faith. That's true. Okay, anyway, we don't need to get sucked into it. Just, but it's all, I think the point is, it's on faith. Because it's faith based, they're not asking for the proof.

[Alyssa Black (Chair)]: Leslie? I was just curious if you at DFR had concerns or thinking that some steps need to be taken in this space.

[Mary Block, Deputy Commissioner of Insurance (DFR)]: It's a tough question, right? Because we obviously don't regulate that, so it's confluence. And so we can't take a step until they cross that line. Colorado has taken the step to ask for reporting, and I know we have the bill. That reporting has been challenged in federal court on constitutional grounds. So far, the sharing plan that challenged it has not won. The case is still in the court system, but they failed to Preliminary injunction request was denied by the federal court on the basis that they did not believe they would win on the merits. So the case is still proceeding. But there is a constitutional challenge, right? Because there's a mix of freedom of religion and freedom of speech and many other potential constitutional rights here that the federal courts will have to sort out. So all Colorado has is a reporting obligation. Were you to try to regulate them, obviously that constitutional challenge would be stronger because you're not just asking for information, you're trying to The argument would be that you're trying to force a religious organization to behave in a certain way or whatever. There would be that tension that would likely result in litigation. Let me ask,

[Alyssa Black (Chair)]: do we understand why Colorado took the step of regulating it? Did they see evidence of misuse that then created a registry or whatever it was that did? Yeah, all of this

[Mary Block, Deputy Commissioner of Insurance (DFR)]: is a reporting. There's no licensing, there's no registration. It's just tell us how much business you're doing, where you're doing it. By the sharing plan. By the sharing plan. So all they ask for is information. I think yes, there's been several states have taken action around when those lines have been crossed and they've stepped into the insurance space. It's hard for us to find that because we have no line of sight into them. So our reporting obligation obviously makes it easier to find it because you know at least you know the actors who you're willing to report. Unfortunately, when you have a reporting obligation like that, it's usually the organizations that are more compliant that tend to report, and the truly horrible ones never report. But that does give you a bit more line of sight into what's out there

[Alyssa Black (Chair)]: so you can ask more questions. Thinking about what Brian was saying about hospitals and being up not, and I totally appreciate that, what he said. The hospital, if someone came and said they didn't have insurance, they wouldn't necessarily know that they

[Mary Block, Deputy Commissioner of Insurance (DFR)]: had this problem. They would

[Alyssa Black (Chair)]: not know. We do have cards. Oh, do you?

[Mary Block, Deputy Commissioner of Insurance (DFR)]: I know all of them don't, but I know some do.

[Alyssa Black (Chair)]: Any other questions? I'm wondering if, sort of, in your opinion, because in this bill, we're talking about short term limited duration plans. We're talking about association health plans. We're talking about age rating, we're talking about sort of, it seems like, fixes to or other options for the unaffordability crisis, I'm not sure which it is. The affordability crisis due to our increasing premiums, obviously. Would you say that as insurance becomes more unaffordable, that people are looking and seeking other options for any health care coverage and that health sharing plans might become attractive to more people who are searching for affordable coverage in any way they can get it.

[Mary Block, Deputy Commissioner of Insurance (DFR)]: I would have to say probably, if people are looking for options, can Google and they can find this as an option. The options obviously that we put out there are things that we regulate and can control, and most of which are falling to the ACA other than the short term limited duration. So they have those mandatory benefits. This obviously doesn't and we don't have the control, but you can certainly find it if you Google.

[Alyssa Black (Chair)]: Okay, thank you. I wanted to get a little information on it because I know we've had that bill sitting there and it's 102 and it's essentially what Colorado Yeah, it mirrors the color. It's a reporting requirement. And I was thinking about it in the context of this bill with some of the other things and the things that you do regulate. So I really appreciate you coming in and walking us through that. All right. All right. I think we are done for the day. So we are back here at 9AM tomorrow.

[Brian Cina (Member)]: Oh, Zoom.

[Alyssa Black (Chair)]: No. No. That's right. Because it's not Wednesday.

[Brian Cina (Member)]: It's Thursday. Night if you want.

[Alyssa Black (Chair)]: Another high day. How many no matter how many times you don't tell me it's Thursday. I just keep thinking it's Wednesday. Just going

[Brian Cina (Member)]: snow. Oh, I know. It's not supposed to be nice. Are you reconsidering the schedule at

[Alyssa Black (Chair)]: all