When Maria Moeller went into the operating room for the cancer occupying her abdomen, her husband, Ron Moeller, followed behind with a weight of uncertainty.
The Moellers, a retired Helena couple, joined a health care sharing ministry in 2017, two years before Maria Moeller’s surgery. Generally, such organizations are formed by religious organizations to allow members to share health care costs among themselves, typically at a cheaper monthly cost than insurance; for the Moellers, the health care sharing plan cost roughly half of their insurance plan. The size of health care ministries can fall anywhere between a small church community and a nationwide organization.
The Moellers secured a plan with Unity Healthshare, a sharing ministry administered by a holding company called Aliera. Aliera claims to be neither an insurance company nor a health care sharing ministry but provides services to ministry members through its subsidiaries. Still, Ron Moeller said his communications always went through Aliera.
The brochure from Aliera listed cancer among the major medical events that would be covered. But but by the time Maria Moeller entered surgery, her husband Ron Moeller had spent months going round after round with Aliera trying to secure payments for chemotherapy and doctor visits. The expenses eventually totaled over $180,000. The health care sharing ministry had refused to cover it all.
“I actually went into (Maria’s) surgery not knowing if it was going to be covered,” Ron Moeller said in a recent phone interview.
He didn’t know it at the time — June 2019 — but Aliera and its subsidiaries would cultivate a reputation in the coming years as the posterchild for exploiting the health care sharing ministry’s exemption from insurance regulators. The Affordable Care Act came with a carve-out for health care sharing ministries. Insurance companies, for example, are required to spend no more than 20% of customers’ premium payments on administrative costs, so that 80% of the money is available to cover health care costs. The Oregon Division of Financial Regulation found only $16.03 out of every $100 an Aliera member pays in premiums goes toward paying members’ medical expenses. Last fall, the New York Department of Financial Services filed charges against Aliera and Unity, which had by then changed its name to Trinity, alleging it deceived customers while operating an illegal health insurance business. Trinity has since changed its name again to Sharity.
The Moellers sued Aliera and Trinity in 2020 alleging breach of contract and fraud. After filing the lawsuit the sharing ministry did pay “some” of their claims, but the process has been so convoluted that the Moellers are unclear what has been paid for and what hasn’t.
“Unfortunately, some of these so called sharing ministries don’t share much at all; they are just con games that are set up to steal money from Christians,” John Morrison, the Moellers’ attorney in their lawsuit against Aliera, said in an email. “They rake in millions and then leave members high and dry when they get sick. It’s a double whammy because people lose their premium dollars and then don’t get the coverage, which means either they don’t get the care they need or they wind up with a huge debt.”
Legislating the unregulated
Estimates from the industry suggest between 15,000 and 18,000 people in Montana are members of these ministries. But because they are unregulated as religious organizations, the state has no clear understanding of how many ministries operate in Montana.
Earlier this year, the state Legislature passed Senate Bill 149, which set some ground rules for health care sharing ministries to operate in Montana. Operate outside SB 149’s definition of a healthcare sharing ministry, and the state auditor’s office can prosecute and fine the organization.
Tom McGillvray, a Republican senator from Billings who sponsored SB 149, said he first learned of the ministry option from his clients when he was a financial advisor.
“At first I was kind of skeptical,” he said in a recent phone interview.
That was until 2012, when McGillvray said his premiums reached $1,500 a month.
“I just said, ‘I’m not doing that,’” he said.
McGillvray reviewed a few ministries; who they were for, who they weren’t for, what the plans covered and what wasn’t. A typical health care sharing ministry may require members to show that they attend church. They also won’t, for example, typically cover pregnancies out of wedlock or an abortion.
In the “gold plan” with his health care sharing ministry, the cost to cover McGillvray and his wife is $377 a month.
“This was a no-brainer for us,” he said. “Now I’m paying $5,000 a year.”
In the spirit of sharing, McGillvray's ministry, Christian Healthcare Ministries, also sends out a monthly newsletter, where members can voluntarily contribute to another member who is experiencing high costs of unexpected medical needs.
"It's truly a community of commonly shared ethics and believers," he said.
But the other side of the ministry experience is no guarantee that the medical needs — like Maria’s surgery — will be covered when they arise. Pre-existing conditions can also be cause to deny a claim. This, regulators say, is what makes ministries "not insurance."
McGillvray’s bill sought not to force sharing ministries into better coverage practices but to draw a distinct line between ministries and insurance.
Most of its debate circled around two components. One was a provision that mirrored language in the ACA, which states health care sharing ministries must have been in existence prior to 1999 in order for their members to avoid the “individual mandate” penalty for not participating in the insurance market. The other component in Montana’s SB 149 prohibited ministries from using commissioned agents to sell their plans to members.
Ministries from around the country traveled to testify on the bill, although some testified in support of the bill and others came out against it. Proponents said the 1999 provision was important because if the ACA’s individual mandate, which was struck down in 2019, was reinstated, then members in Montana could be penalized on their taxes if their sharing ministry was formed after 1999.
Jeff Laszloffy, president of the Montana Family Foundation and a member of a health care sharing ministry, told lawmakers the 1999 provision would help sort out the longstanding ministries and new ministries that look and act closer to insurance companies.
“We don’t want to lose what we have,” Laszloffy said. “We’re concerned the two could become conflated and our ability to participate in a sharing ministry could be jeopardized if that happens.”
Opponents to the 1999 provision, however, called it an arbitrary deadline that would prevent them from offering coverage to possibly thousands of Montanans.
One opponent, Christian Care Ministry, a sharing ministry that does business as Medi-Share, boasts 400,000 members nationwide and 1,000 in Montana. The organization argued barring its commissioned agents could put members' access to health care in jeopardy and that the state shouldn't be encroaching on how a religious organization compensates its employees. The organization paid a lobbyist $15,000 in March alone to oppose SB 149.
McGillvray said the ministries successfully lobbied the bill into a compromise: the 1999 provision was struck out, but the prohibition on agents remained.
“It was get the bill out without (the 1999 provision), or no bill at all,” McGillvray said.
The State Auditor’s office was among those who backed the agent prohibition in McGillvray’s bill.
“That was a big deal for me,” State Auditor and Insurance Commissioner Troy Downing said, saying the use of insurance agents further blurs the line for consumers who are trying to research options. “If you look or act or smell like insurance, then you clearly fall under the purview of this office.”
Downing praised other provisions in McGillvray’s bill, like the requirement that health care sharing ministries provide disclaimers — in 12-point font at a minimum — on brochures and other materials indicating that the ministry plans are not insurance and coverage is not guaranteed. Sharing ministries must also get an annual audit in order to meet the state’s definition of a sharing ministry, and that audit must be made available to the public upon request.
The State Auditor’s Office has the authority to prosecute, fine and exile sharing ministries from the state for operating an insurance business without a certificate. Consumer protection issues, Downing said, are forwarded to the Montana Department of Justice.
The process is complaint-driven, so the auditor’s office isn’t actively rooting out fraudulent ministries. But Downing said his office is also working to do more to educate Montanans on the difference between sharing ministries and insurance, as well as the risks involved with joining a sharing ministry.
“I think there’s a lot of folks who have had very good responses and experiences with these health care sharing ministries and there’s obviously been a few that haven’t,” Downing said. “Since it is a non-regulated industry, it doesn’t fall under our regulatory authority, and the onus is on the consumer to properly research it and vet it.”
But in the Moeller’s case, Aliera’s brochure specifically listed cancer under "examples of covered major medical events," along with heart attacks, surgeries and hospitalizations.
In part, it was this promise to pay certain medical needs that led U.S. District Court Judge Sam Haddon to rule on June 30 that the contract Trinity, Aliera's plan provider had with the Moellers was, in fact, insurance according to Montana law, regardless of Aliera's disclaimer that the plan was not insurance. A week earlier, a federal judge in Georgia noted five state insurance commissioners have determined Aliera and Trinity were conducting insurance business in their respective states.
Aliera's founder, Timothy Moses, was convicted of federal securities fraud and perjury in 2005 in connection with a prior business. He was sentenced to six years in prison followed by five years of probation, which was terminated approximately six months prior to Aliera's creation.
An email to Trinity's attorneys seeking comment on Haddon's finding was not returned, nor was an email to Aliera's corporate office.
The last time a judge ruled a health care sharing ministry was selling insurance in Montana, a state District Court judge ruled Christian Care Ministry, doing business as Medi-Share, had also engaged in insurance practices. A jury ordered Medi-Share to pay the plaintiff, a pastor who said the ministry would not pay for expenses related to a heart condition, $850,000. Shortly after the judge’s filing, the state auditor kicked Medi-Share out of the state. That state auditor was Morrison, the Moellers’ attorney in their civil case against Aliera.
In 2017, then-Auditor Matt Rosendale issued a notice allowing Christian Care Ministry back in the state, saying its new practices met the requirements to operate in Montana again. Evelio Silvera, vice president of communications and government affairs for Medi-Share said the organization did move away from a structure that "was blurring the line" with indicators of insurance companies. He said Montana's state auditor raised issues that led the company to "re-invent" its practices to be more clear about its sharing ministry operation.
"We took to heart the comments that were made," Silvera said.
Less than two weeks after Judge Haddon found that Aliera and Trinity had provided an insurance contract to the Moellers, Trinity filed for bankruptcy. A week later, Haddon put a stay on the case, halting all proceedings until the bankruptcy played itself out.
The Montana State News Bureau asked Downing what Haddon’s order triggers for his office.
“On this, since it is acting as insurance, what it gives us the authority to do is to prosecute and find based on doing insurance without a license in the state of Montana,” Downing said.
The bureau asked if the auditor’s prosecution team was teeing up proceedings against Aliera, or if the bankruptcy had stalled those proceedings, as well. Downing said he would check with the prosecuting attorneys. A week later, a spokesperson for the auditor’s office said the legal team is “aware of it and tracking it closely and looking for opportunities to advocate for Montana consumers.”
Back in April, the Legislature shot down an amendment that would have required the state auditor’s office to examine health care sharing ministries filings’ to determine if they meet the criteria for the exemption to regulations, to take on a more active enforcement role. The amendment would have also required ministries to apply 80% of their members’ payments to eligible medical expenses, and members would not be forced into arbitration if conflicts arise.
It's unclear from the House debate how the amendment would have fared had it not come so late in the session. The amendment was proposed April 15, and the House of Representatives was under a one-day deadline to send amended bills back to the Senate. House Speaker Wylie Galt did not speak directly to the amendment, but he told the House floor that delaying the process with a lengthy debate would kill the bill. The amendment died 32-67, and the bill passed.
The amendment was brought by Rep. Ed Stafman, a Democrat from Bozeman and a rabbi who said it would preserve the “great intent” of the ministries while preventing consumer fraud.
McGillvray, the Republican who sponsored the bill, said he’d like to see the enforcement process work with what survived lobbying and transmittal deadlines.
“If Aliera is a bad actor I hope they get booted out,” McGillvray said. “Let the good guys follow the law and do it right, just like any other business model.”
“There are going to be bad actors in any field,” he said. “It’s frustrating that you would have an ethical religious organization being a bad actor, but frankly I think there are some people are using sharing ministries for nefarious means. There’s no guarantees on anything in life, that’s why you do your due diligence.”
Ron Moeller is still smarting from the ongoing litigation and, now, the bankruptcy delay. He has tried to handle the maze of bills and paperwork through this point, but he knows Maria has felt the extra stress from it.