Traditional health insurance can make people feel trapped. Premiums keep climbing, deductibles stay high, and many families rarely use enough healthcare to reach the point where their plan starts paying much.
In this episode of the Bill of Health Podcast, presented by Core 360 Benefits Group, I’m joined again by Richard Walton, CEBS, of Sedera for part two of our conversation about medical cost sharing and healthcare alternatives.
Episode 7 covered the basics of how health shares work. This time, we get more practical and dig into the questions that usually come up once someone starts seriously considering whether to leave a traditional insurance plan.
We talk about preexisting conditions, what it really means to become a cash-pay patient, how Sedera helps members negotiate medical costs and why health share members are not expected to navigate large bills entirely on their own.
Richard also explains how medical cost-sharing communities think about financial stability and why consumers should look closely at a health share’s track record, rules and reputation before making a decision.
In his Episode of Bill of Health:
Richard and I discuss:
• What to consider before leaving an employer-sponsored health plan
• How health shares handle preexisting conditions
• Why becoming a cash-pay patient does not mean navigating healthcare alone
• How medical bills and scheduled procedures can be negotiated before or after care
• Why knowing the true price of healthcare can change the way you spend
• How health share communities approach financial sustainability
• Who may be a good candidate for medical cost sharing
Preexisting Conditions and Health Shares
Preexisting conditions are one of the first concerns people raise when they begin exploring medical cost sharing.
Health shares do not handle them the same way traditional insurance does. Richard explains that Sedera uses a graduated sharing approach for certain preexisting conditions, allowing the amount eligible for sharing to increase over time.
That makes it especially important to understand the specific membership guidelines before joining. Every person’s situation is different, and no one should assume a health share works exactly like an insurance plan.
Becoming a Cash-Pay Patient
Operating outside a traditional insurance network can sound intimidating, but cash-pay healthcare does not mean paying every large medical bill upfront or negotiating everything by yourself.
For emergencies, the priority is getting care. Once the bill arrives, Sedera can help review and negotiate the cost before payment.
For scheduled procedures, members can request a good faith estimate in advance and compare the price with other options. In some cases, moving a procedure from a hospital to an outpatient facility can significantly reduce the cost without changing the physician providing the care.
The goal is not to become an expert in medical billing. It is simply to understand that you have options and support.
Shopping for Healthcare
Healthcare prices are often treated as if they are fixed, even though they can vary dramatically from one provider or facility to another.
Richard’s point is simple: consumers already know how to shop. If you would drive to another town to save $1,000 on a vehicle, you can apply the same mindset to healthcare when the situation allows it.
Tools, direct primary care providers and medical cost-sharing communities can help make those comparisons easier.
Can a Health Share Be Financially Sustainable?
Long-term sustainability is another important question for anyone considering medical cost sharing.
Sedera operates as a nonprofit medical cost-sharing community rather than an insurance company holding large reserves. Richard describes the model more in terms of ongoing community cash flow, membership size and the ability to manage large medical needs as they arise.
Consumers should still do their homework. Look at the organization’s track record, understand its guidelines and talk with people who have experience using the model.
Jargon Jar: Claim vs. Need
Traditional insurance uses the word claim. A claim is a contractual request for payment under an insurance policy. Health shares use the term need.
A need is a medical event, illness or injury for which a member asks the sharing community for financial assistance according to the organization’s guidelines.
The language reflects an important difference between the two models: insurance is based on contractual coverage, while medical cost sharing is built around voluntary community sharing.
About Richard Walton
Richard Walton, CEBS works with Sedera and has spent more than two decades in the employee benefits industry. His work focuses on medical cost sharing, direct primary care and alternative approaches to paying for healthcare.
Connect with Richard:
LinkedIn: Richard Walton, CEBS
Email: rwalton@sedera.com
Phone: 806-679-0816
Sedera: www.sedera.com
Learn More
Interested in exploring Sedera medical cost sharing through Core360 Benefits Group?
Use the Core360 Sedera affiliate link: http://www.1enrollment.com/950517
To learn more about individual health insurance options, Medicare planning and healthcare consumer strategies—or to schedule a consultation—visit:
https://core360benefitsgroup.com/
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Disclaimer
This podcast is provided for educational purposes only and should not be considered legal, tax, investment or insurance advice. Individual circumstances vary, and listeners should consult qualified professionals regarding their specific healthcare and financial situations. Opinions expressed by the host and guests do not necessarily reflect the views of any insurance carrier or affiliated organization.
Chapters
00:05 Welcome Back to Bill of Health
02:07 Why Bill Believes Health Shares Deserve a Look
05:01 Why Health Shares Don’t Need a Network
06:13 How Preexisting Conditions Are Handled with Health Shares
12:48 Why Paying Upfront Can Lower Healthcare Costs
13:44 What Happens When a Cash-Pay Patient Goes to the ER?
17:08 Can Health Shares Be Financially Sustainable?
20:12 Jargon Jar: Claim vs. Need
23:43 Who Is a Good Candidate for a Health Share?
25:00 How to Explore Your Options
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