Supposed clarification from SHBP

I emailed the state trying to get clarification on the requirements i.e.-can we use previously completed sup. diet, if we had to wait until Jan.  all those questions we have been asking.  I did this because when I talked to the UHC/Optum folks, they said it was the employer that set the rules.  Tell me if I am crazy, but the reply I got from the SHBP sounds like we just have to do what UHC normally requires of all patients seeking surgery.

"The basic purpose of the SHBP is to provide healthcare coverage for the
treatment of an illness or injury for our members and their enrolled
dependents. We are pleased to inform you that the treatment of Morbid
Obesity at approved Centers of Excellence will be a covered benefit
under the Health Reimbursement Account (HRA) and High Deductible Health
Plan (HDHP) Options effective January 1, 2009. Members must meet the
medical criteria as outlined by the vendor under the option that they
are enrolled in. You must contact UnitedHealthcare or Cigna if you have
additional questions regarding this benefit. As an added note, the HRA
and HDHP are the only options that will offer this benefit.

Hope this was helpful."

Anybody  interpret this differently??

To me, it sounds like your previously supervised weight loss program would be acceptable.  The issue is not that that insurance company wants to supervise your program, but that they want to make sure you have tried that method of weight loss.  Good luck!

it wasn't so much a question of them supervising it.  It is that they told me the state would set the approval requirements, and the state is saying that we only have to meet the requirements of UHC to get approval.  I don't really care about the hhops to jump through, I would just like to know what they are.

DId you hear about the two hospitals you have to use in order for SHPB to pay? Its JOhns creek, and Atlanta medical center. I called and asked could I record them gove me the lsit of guidelines to pre appove for surgery.
1. complete MYUHC health risk assesment on line.
2. Contact someone in the Bariatircs  center t o get your paper work together
3. You must use a center of excellence Dr's and use a center of Excellence hospital Atlanta medical and Johns Creek
4. 6 months PCP supervised diet and excersise program
5. 6 months behavioral OP counseling (I don'r know if this includes theose sessions your sugeon makes us go to. They could n't answer that)
6. Mental or psych evaluation
7. 6 months superived diet with a nutrionist it may have to be the one they will refer you to.

Who was it you talked to?  The Atl. Bariatric center at John's Creek said they new nothing about a 6 month behavioral counseling.  For the state, Optum is running the deal for UHC, and they have nothing either.  UHC referred me to Optum.  Be careful, some clinics and Doctors have you go through things that are not necessarily required to get approval.  I have an appt for the 24th.  I will know more then.  Someone I know has the same UHC HRA ins with the state and Dr. Macik's office has told her what to do and there was no OP counseling at all.  Just a Psych and dietician consult.   Still quite confusing.

That's because they still don't have their acts together.  I wouldn't expect the doc's office to know about the 6 month behavioral counseling.  They are just stating the UHC rules that are standard.  The behavioral counseling appears to be a caveat that the SHBP has tacked on to the rest of UHC's rules.

You are right, still confusing.  But I think the whole point with using UHC is that you will be "managed" by a case manager/utilization review nurse at Optum.  They are supposed to walk you through the steps.

This was my understanding of the whole UHC process (and why I went with Cigna).
-Elli

The SHBP standard answer was they were doing nothing different from what UHC normally requires.  After talking with a couple of doc offices, UHC has never required a 6 month behavioral anything.  Just the standard-Sup. diet, psych, dietconsult and tests.  I guess we won't know until Jan 1...but knowing how the state operates, it could be March.  Lucky for me, job wise, I have to wait til June 1 to have the surgery, so I have the time. 

You see, and for me, the sooner the better.  I started this road February 2008 and I'm more than ready.  I can't do the surgery over the summer because I'm supposed to take 2 classes this summer.  I will take the time off of school and they will live with it.  I have 9 sick days currently and I have the buy-up plan for the short term disability if I need it. 

If the stars align correctly and the insurance cooperates, I could have my surgery in February/March.

If I had not had such a rough year this past year and burned up all of my sick days.  My 6 yr old had heart surgery and my wife was in and out of the hospital with adhesions from her RNY while she was pregnant.  I switched school districts, so I can't exactly buck the system.  Good luck and I look forward to your updates and seeing you progress. 

Your 6 year old had heart surgery?!  YIKES!  That's a rough year all by itself!  I hope she's all better now.  No fun when children are sick

-Elli