Insurance insight desperately needed!

Hello all...let me try to explain this so that perhaps someone can help me. I am a former City of Chicago employee. I left my job, moved to another state yet I continued with COBRA coverage (United Health Care). I have found a doctor to perform lap band surgery for me and have completed all of the steps. My doctor just informed me that UHC has a medical exclusion and I would have to self pay $17K in order to get the procedure done. I am in school and unable to work full time in order to gain insurance. In a nutshell, in November I will be able to change my COBRA coverage - I am thinking of going with Blue Cross Blue Shield of Illinois - PPO. My question is - do they cover the procedure or do they have medical exclusions. Any help anyone can provide will be greatly appreciated.

With BCBS and all insurance plans it depends on what the particular policy says. Just like your UHC policy has an exclusion, some of those plans may also have exclusions. It just depends on how "rich" a particular policy is written. Then with many of the BCBS & other company's policies they have guidelines of supervised diet trys during a certain time frame. So, there really isn't a cut and dried answer to your question.

I have BCBS PPO and my plan does cover the procedure, after you jump through the many hoops they have laid out in the plan. Here is what My policy reads ? Body Mass Index (BMI) of greater than or equal to 40 kg/meter squared OR a BMI greater than or equal to 35kg/meters squared with at least two of the following co-morbid conditions which have not responded to maximum medical management and which are generally expected to be reversed or improved by bariatric treatment: 1. Hypertension 2. Dyslipidemia 3. Type 2 diabetes 4. Coronary heart disease, and/or 5. Sleep apnea ? A documented five-year history of morbid obesity (BMI greater than or equal to 40 kg/m squared). ? A documented failure of twelve (12) continuous months of compliance with medically supervised non-surgical methods of weight reduction. Medical supervision must occur under an MD, DO, or nurse practitioner within the previous 24 month period prior to the request. . A medically supervised weight management program is expected to consist of: 1. Nutritional therapy or medical nutrition therapy including a very low calorie diet (e.g., MediFast or OptiFast) unless contraindicated., 2. Behavior modification or behavioral health interventions, 3. Supervised increase in activity, 4. Pharmacologic therapy (unless contraindicated), 5. Maintenance support to continue to encourage nutrition choices to reduce health risk factors and maintain a healthy lifestyle. ? Evaluation by an independent, appropriately licensed professional counselor, psychologist or psychiatrist who is unaffiliated with the surgical program. This evaluation must document: 1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations; and 2. Evaluation of psychological comorbidities that contribute to weight mismanagement; and/or eating disorder. ? Documentation of willingness to comply with preoperative and postoperative treatment plans; and ? Growth has been completed (18 years of age or documentation of completion of bone growth). HOWEVER - every BCBS policy is different. It all depends on where your coverage comes from (the employeer) and any exclusions they may have. I would definatly ask before taking on any insurance what the policy will cover in regard to barariatic surgery and what qualifications must be met before you will be approved. The HR personal (through cobra) should be able to provide you a phone number to the company. Also - since you are unable to work - are you eligable for medicaid or a state funded insurance program? Just giving you another option to look at. Good luck!