Exclusion

I was wondering if anyone who had a policy with an exclusion for WLS had been able to have it covered. I was thinking about going with Optimum Choice, It is a large group policy but they do have an exclusion about WLS. I do know about the Maryland mandate, I was curious who else had this exclusion on a large group policy and did get approved.

I would first say that it's important to look at the POLICY you are offered, not just the company as a whole. I had optimum choice and I was covered under my POLICY with that insurance company. I would not want others to ready your post and think that just because they have optimum choice, they are not covered, because it's the policy you are on, not neccessarily the company you are with. Here is the Maryland mandate, it's long. In addition, insurance companies are starting to implement a requirement that the surgery take place at a "center of excellence", which is just a rating hospitals receive after application/qualification. Health Insurance - Treatment of Morbid Obesity ? Revises the duties of the Task Force to Study Utilization Review of the Surgical Treatment of Morbid Obesity to require the Task Force to: (1) review the literature on the surgical treatment of morbid obesity; and (2) recommend a set of guidelines or criteria that are appropriate for the utilization review of the surgical treatment of morbid obesity, and reasonable procedures for documenting patient compliance with the guidelines or criteria. ? Requires the Task Force to report its findings and recommendations, in accordance with § 2-1246 of the State Government Article, to the Senate Finance Committee and the House Health and Government Operations Committee on or before December 1, 2007. ? Requires the Maryland Health Care Commission and the Maryland Insurance Administration to provide the staffing for the Task Force. ? Requires the Maryland Insurance Administration to report, in accordance with § 2-1246 of the State Government Article, to the Senate Finance Committee and the House Health and Government Operations Committee, for the 12-month period following the date the preceding report is provided: (1) the number of complaints filed with the Administration relating to the denial of coverage for the surgical treatment of morbid obesity; (2) the health insurance carrier that denied coverage and the reason given for the denial; and (3) whether the Administration upheld or reversed the denial of coverage and the basis of the decision. ? Removes the sunset provision from Chapter 486, Acts of 2004 that would have abrogated § 15-839 of the Insurance Article. ? Requires that the Maryland Insurance Administration shall adopt regulations: (1) clarifying the applicability of the National Institutes of Health's guidelines to the utilization review process for primary bariatric surgery for insurance carriers and private review agents; and (2) establishing reasonable documentation requirements for the utilization review of primary bariatric surgery following the recommendations of the 10 Task Force to Study Utilization Review of the Surgical Treatment of Morbid Obesity as set forth in the report of the Task Force issued November 2004. Effective date: June 1, 2005

Thank you very much for the info!!! I in no way would want anyone to think Optimum Choice didn't provide coverage for this surgey, as you stated it's my company and the policy they choose to offer their employees. What should I be looking for in particular in the policy?? What questions should I ask them? They have been very helpful in answering my questions during my research in the policy thu far.

I would forget about the calling process, and forget about how many employees are in your company. Again, you can call and talk to fifteen people who tell you it's covered or not covered but when it's time for approval of a consultation and/or surgery, it comes down to what's in writing and only your insurance company can give you that. Email your insurance company directly with this information: Your name, your address your policy/member number and ask them: Please advise of the weight loss exclusions, if any, under my policy? give them your name and your email address and they will respond in writing and it will be a very standard response from their manual, but it will tell you if its covered and it will tell you what the "requirements" are. You'll have that written documentation to take to your surgeon and believe it or not, it helps them do their job of getting you approved for surgery. Try it, it's a good idea. Good luck.

I had an exclusion with BCBS NC. I changed to Optimum Choice MD. The OC booklet said it was excluded, however coverage was verified under a seperate letter which was with the policy. I believe they use the same book for all. But Maryland is mandiated and I believe they have to cover. As long as you have over 50 employees. You can call them ahead of time to verify coverage. And if they tell you they do not cover, call another time and talk to someone else. I called ahead of time and they said they covered. My paper work was just submitted Monday and I have not heard anything yet. When I was with BCBS. I heard the very next day. Even when I appealed. If it is excluded. It will be tough to get WLS covered.

My employer had an exclusion under their plan, but because I chose the optimum choice plan, which was the HMO plan, they were required to follow the MD state law. Samantha

What type of requirements do Optimum choice require for approval. I do understand every plan is different, I was just trying to get some type of idea. Thanks for all your help and info

Optimum Choice (which was a MAMSI co, which is now United Healthcare) had several requirements... -medically necessary (sleep apnea, diabeletes or HTN, etc) -6 month diet (I submitted my medical documention provided by my PCP going back to 1982, at which time I was 9 years old, that documented all my heights, weights (I was obese by age 11) and all the weight reduction strategies he implimented and I had seen him several times a yeardue to multiple medical issues; not necessarily due to my weight)-I had never been so thankful for a diligent PCP that documented every friggin thing! I know this is the hardest documentation to obtain, and many peole have to start "fresh" with the 6 month "diet/exercise" attempt when pursuing WLS-if you have to, just do it, it can take longer to obtain all the necessary documentation. I was just "lucky" to have so many docs between the ages of 9 and 32, that I had all the proof needed that I had "tried" to lose the weight on my on own! -consult with PCP, WLS surgeon, psychiatrist and nutritionist/dietician Because I had tried to get approved several months earlier when I had a BCBS policy and had an exclusion, I had all those consults amd paperwork ready by the time my Optimum Choice kicked in. Unfortunately my PCP that had been treating me 22 years was only considered a "specialist" in network and not a PCP, I had to get a new PCP. Luckily my parents' PCP was in network and agreed to see me. My policy kicked in July 1, 2005. I saw the new PCP July 10th and the surgeon submitted the paperwork the 13 (Optimum requires a lot of forms to be filled out by the docs). My surgery was approved a couple of business days later. It had been a long torturous road, and I have never liked HMOs on principle, but they really came through! Keep me posted! Samantha

Samantha, Thanks for sharing all your info. I tried to get approved with BCBS and they denied me. They said my BMI was not over 40 for 3 years (but it was pretty damn close) It does exceed that now and them some I do have sleep apnea and they wouldn't even consider that, it's just been a very long drawn out process with them. We are going with optimum choice and try to go that route, but I do know going in they do have that "exclusion for weight loss surgery". I have been going to my PCP since Aug 2005 for my supervised diet and I have continued to go every month, so right now I'm on a 10 month supervised diet LOL!!!! I've had my consult with my WLS surgeon and did have a psyc. eval in Aug 2005 so that's not a big deal to go back and get that updated. Again, Many thanks for sharing your info. J

I was glad to see all your reply's. I also have Optium Choice/Mamsi. I'm on my 5th month for my supervised diet. Only 1 month before they submit. I have been so worried about not getting approved. But after reading all your reply's I feel much better. Thanks to everyone. I do have a big concern.... which I'm sure is minor. How long does is usually take for your insurance to send the approval. I would love to have my surgery by end of Sept 06