SHBP New Update

Just thought I'd give an update to anyone trying to figure out the SHBP coverage for WLS...

It seems that the SHBP and Cigna are finally in the same chapter (and maybe even the same page.  SHBP confirmed that it is ONLY the HRA and HDHP options of UHC and Cigna that will cover the surgery.  Cigna had previously told me otherwise.  Today, Cigna reported they had a meeting (today) and it was clarified for them that it is only the HRA and HDHP.

BE AWARE:  the way the SHBP has written the policies with UHC & Cigna, you are limited to which hospitals you can use.  For Cigna, you have to use one of the hospitals listed on their Certified Bariatric Center list.  These are not necesarily hospitals that have the Center for Bariatric Excellence certification...these are centers that CIGNA has "certified".  They are Atlanta Medical Center, Emory Crawford Long and Northside.  For UHC, there are 2 hospitals.  Forgive me, I only know 1 of the hospitals and that is Emory Johns Creek. 

Please be aware of this information as you make your open enrollment decisions.  And make your own phone calls (don't depend on my word as gospel).  I've been so afraid to make the wrong decision during open enrollment that I'm being very anal retentive about the process.  And I'm just posting the information so maybe when you do your own checking, you don't have to let your fingers do as much walking, so to speak.

Good luck to all SHBP members!

Elli

Thanks for the update.  Today we had an SHB fair at my office and it was very upsetting because know one could answer the questions regarding WLS.  I even called DCH to get a copy of "summary plan description " for UHC and Cigna and I was told that the 2009 plans were not available.  I asked the rep. for DCH how do they expect people to  sign up for health benefits when there is no updated plan to study and look over.  The rep. could not answer my question, she stated that the plans from last year are the plans that they will be using for this year.  I reminded her that we did not have Cigna last year and that we had very different levels of coverage, of course I didn't get a reply on that statement.  This is so frustrating.  I want to see in writing that they will cover WLS before I make any decisions. 

I've been trying to get the summary plan descriptions for 3 weeks now.  Final verdict is that they come directly from the health insurance providers, they aren't updated yet, and they won't be available until AFTER January 1st.  I asked the same questions, how can I compare "apples-to-apples" when I can't see the documents?!  It's frustrating.

I also wouldn't expect anyone they send out for a health fair to know anything.  But as I stated in my initial post, they are on the same page now.  You can take either the HRA or the HDHP of Cigna or UHC.  Technically, that is in writing as it's in the decision making guide.  I really wanted to go with Cigna, but the doctor and hospital I'm already established with is on the UHC plan.  And I REALLY like my physician...and more importantly, I TRUST him.

-Elli

Are those the only hospitals in the state that are certified to do it, or just the ones in the Atlanta area? This is very aggravating that they expect us to make an informed choice without information! We are swapping from BCBS, so we have no idea of how these compare to it.

There aren't any hospitals/doctors in south Georgia? That's awful. I can't go to Atlanta every time I need to see a doctor about this.

Remember, people go to different states and even different countries all the time to have WLS now.  If your only choice for surgery is Atlanta...you do what you need to do here, and hopefully, your PCP will work with your surgeon to provide what you need at home...meaning less trips for you.

-Elli

The 3 hospitals I listed for Cigna, are the only ones in the state to use.  If you go to Cigna.com...click on "Provider Directory"... scroll down the page a bit...on the left hand side of the page is a link "CIGNA Certified Hospitals for Bariatric Surgery ".  Only 3 hospitals are listed in all of Georgia.  If you read this document, don't be fooled by the 2nd paragraph that states "Our certification is important information you may wish to consider as you decide where to seek services.  You are not required to receive services at a certified hospital or from a doctor associate with a certified hospital. ..."  I questioned the semantics of the paragraph and my customer service person did a little research.  If you had Cigna with some other employer, you could potentially use a different facility.  BUT the way the contract between SHBP and Cigna has been written, we HAVE to use one of those facilities if we choose the Cigna plan.  I don't know if you are a far distance from Atlanta if you could get "special approval" for a different hospital.  That's one of the answers I think they may have if you call the health plan directly. 

As far as UHC goes?  When I talked to them the other day, the customer service rep said I'd have to use one of the two hospitals he listed (both in the Atlanta area) if I'm not mistaken.  Now, whether he gave me those 2 hospital names based on me living in Atlanta or if those are it for the whole state, I don't know.  Again, this is something the health plan should be able to answer if you give them a call.

I know when I call, they ask for my name.  I wonder if the health insurance companies charge the SHBP per call.  If so, I'm single-handedly going to make Cigna & UHC wealthy!  And, if that's the case, maybe next time SHBP will provide more written information up-front.

Good luck!
Elli

I have BCBS and am going to Dr. Masik in Atlanta.  I am on the south side of ATL in McDonough so it is a ride and a lot of traffic to get there but not as bad as you might have.  I only had to make one trip.  The office assistant gave me a paper of items I need so she could submit to BCBS.  To get that info I went to the doctors of my choice.  info needed was primary care phy 5 year assessment of your weight issues, one phys visit, one dietician visit and $250.00.  I actually called her to make sure she got all the info from all the different doctors and gave her my visa card for the $250.00.  You may not have to make many trips into ATL.  They told me that BCBS is very quick with approvals.

I had my wife call UHC yestereday to try and get clarification on what will be required for approval.  The guy she spoke to said they req.  6 months of psych counseling and it can't start until after Jan.1.  They didn't say anything about supervised diet.  I can see if the person has no co-morbidities they might need it.  I have several and have sleep apnea that will only be controlled by weight loss or a tracheotomy!  I am a teacher, if I have to wait 6months to get approved and then try to schedule a date, I am in trouble.  I will be out from June 1 to the end of July.  I can't take a month off during the school year.  ANYONE heard any different info???

When I talked to UHC early this week, they didn't have the information about what would be required.  He said it was starting to trickle down.  While on the phone with me, he got a bit more information and didn't say psych counseling...said "behavioral counseling".  I'm thinking Weigh****chers may cover that.  I don't know why you wouldn't be able to start before Jan1st. 

I will be following up.  When I have further information, I will post here.

FYI, Cigna is not as stringent with their bariatric surgery policies (as it seems).  Cigna's bariatric policy is on their website.  Use the search engine and type in "bariatric surgery".  You are looking for "coverage policy number 51".  Keep in mind, this is their overall policy...since SHBP's policy seems to be "still being written", it's possible Cigna may have to add an addendum for SHBP policies to include "behavioral counseling" if that's what SHBP wants.

I just view all of this as SHBP's way of making it difficult for us to actually HAVE the WLS now that they will cover it.

-Elli