What Georgia SHBP will pay for Weightloss Lap band surgery

My name is Martina Im 29 years old and currently weigh 307 lbs.� I am tired of being over weight and have called yearly to see if my insurance will pay for lap band surgery.� I am trying to loose weight on my own but have been unsuccessful.� I currently have United Healthcare Choice and they do not cover WL surgery.� Can anyone suggest or let me know which Georgia SHBP will cover WL surgery and how much out of pocket you had to pay.� If anyone have used Dr. Scott in Rome let me know what your experience was.� I also need to know would I have to have to have Something like United Health care and a HRA also.� Any help will be appreciated

At open enrollment (in October) you will have to choose 1 of 4 plans...United Healthcare HDHP, United Healthcare HRA, Cigna HDHP, or Cigna HRA.  As of right now, these 4 plans under the SHBP cover weight loss surgery.

As far as your out-of-pocket expense, the plans are similar, but I have the HRA, so that's the one I'm most familiar with.  Also, if you are covering a family, your deductibles will be different (higher) than if you are covering only yourself.  With the HRA, the first $500 of the year comes out of a health reimbursment account that is funded by the SHBP.  The next $600 is COMPLETELY YOUR RESPONSIBILITY.  After that, you pay 15% and SHBP pays 85% until you have paid $1400 additional, for a total of $2000 out of your pocket.  Basically, if you are able to have your surgery in the early part of the year, you will meet your deductible quick and your medical expenses for the rest of the year will be "free".  You can start working on all the requirements for surgery now under your current insurance (I'm assuming you have the HMO or PPO) with your current co-pays.

You would also be able to set up a Health Account where they would take $X.XX out of your paychecks to cover part or all of your out of pocket expenses.  I specifically covered the $600 this year in that manner.  So, they will take out $50 every month to fund that.  Yet, I've already spent this $600 and been reimbursed for it.  Now, I'm working on that 15/85% split.  So, after doctor visits, I get a bill for my 15%.

I think I've covered the basics.  I hope it's understandable.

Talksoupslp, thanks for information you provided.  I now know to start working on my pre surgery requirements under my current plan.  What all will I need to do before surgery I want to get as much as possible done under my current plan so I will not have to pay a lot out of pocket and can have surgery beginning of year.  I know I would have to loose a particular amount of weight before surgery is it ok if I loose weight before my new health plan is started.  Question when you go to doctor under this plan how much do you pay for a regular doctor appt.  I have a family and is wondering how much more it will cost me.  Which surgery did you have.  I want to have Lap Band surgery.

Martina

You can go ahead and do your pre-op requirements now.  You will need:

6 consecutive months physician supervised Dr. Appointments
6 consecutive months support group meetings (call your insurance and ask if it neds to be at
    a Center of Excellence I heard they were adding this stipulation, but not confirmed whether it
     is true)
Psychological Evaluation
Consult with a nutritionist
Approval from a bariatric surgeon

I reccomend starting the Dr. Visits and Support group meetings right away. That way you will have that out of the way by Jan 1, 2011 and you should have your surgery Jan or Feb next year.

I chose the DS (duodenal switch) surgery, but you have to have a BMI 50+ for the state to cover it.


You have the options of the following with shbp:

Duodenal Switch - most effective
RNY gastric bypass - 2nd most effective
vertical sleeve gastrectomy - 3rd most effective
lapband - least effective

I have listed them in the order of effectiveness meaning more weight you should lose and keep off.   Please research ALL your options before you decide. Since, you have several months you should gather a lot of info by then.

Since your BMI is probably too low for DS, I would start my research with RNY or sleeve if I were you.    I am not saying you will fail with band, but the odds would not be in your favor, and you need to go into it knowing that.

Check out the failed surgery and regrets forum. You should notice which surgeries are posted about on there most. That should give you an idea of the potential complications and failures for some procedures. 



As far as payign for wls, you should get the flexible spending account durign open enrollment. Have them take $100-150 per month out of your check pre-tax.  The full year's deduction will be available for you to spend Jan 1. So, for instance if you elected $100 per month deducted, your flex account will have $1200 on Jan 1, 2011 you can use right away.  That way if your wls is early in the year, you won't have to scramble up the money. You will already have it avasilable on your card.  

Your surgery will put you at  your out of pocket max, so expect to spend about $1500 out of pocket for the year. After your surgery  you will have $0 co-pay for everything!!!  That's a great feeling.

 

Currently, under the retiree program, there are two plans under UHC and two under Cigna with SHBP that cover WLS (HRA and High Deductible)  I have the SHBP -UHC and have the High deductible plan (which covers WLS)  without the HRA feature.  The out of pocket for us  the entire year is $3100 for in network care.  This has been a Godsend to my husband and I who has a lot of health issues.  The drawback to this plan is that $0 is covered for any expenses until the deductible is satisfied, which was $2400 for us this year.  After the $3100 out of pocket is met, all in-network charges, including prescriptions are covered at 100% for the year.  I am not sure if the plans are them same for retirees and employees, though.

Since our usual out of pocket is much higher under other plans, this plan made perfect sense for us.  Plus the premiums are lower for this plan.