End of the road. Again.
In March of 05 I started the process to have WLS. Started seeing a nutritionist for my 6 month diet. Picked a surgeon and went to his support meeting. Then I called to find out if WLS was covered by my insirance. It wasn't 
My employer was even willing to purchase the rider policy to cover WLS but our insurance company wouldn't sell it to us. End of the road #1.
Sicne that time I got pregnant, had twins, became a stay at home mom and hubby got a new job, with different insurance. I figured, GREAT, he's working for a hospital.Obivously not a small business so WLS would be covered. But, just to be sure, and before getting started and being disappointed again, I called to make sure. Yep, Alliance PPO coveres WLS, if it's deemed medically necessary.
Once again I begin the process. I've completed my 6 month doctor supervised diet. Picked a surgeon and had my initial consult. Had my appointment set to see his nutritionalist.
Today the nutritionalist office called to tell me that my policy didn't cover nutrition counseling. Not a big deal. I sort of already knew that and figured I'd have to pay out of pocket to see her. Then, she went on to say she called my insurance company just to be sure and she was told I wasn't covered for WLS at all.
How can that be? Alliance covers the procedure. I called to make sure. My husband works for a hospital, in Maryland. How can they not cover it? Turns out that however their insurance is set up they have to follow federal law. Not Maryland law. The hospital itself CHOSE not exclude WLS from it's coverage. Someone actually sat down and made the decision NOT to include WLS in their coverage. They'll cover treatment if I have a heart attack. They'll cover treatment for diabetes. They'll cover testing and treatment for sleep apnea. But they won't cover the surgery that can prevent, or greatly reduce the risk of, those same problems. The woman I spoke with at the insurance was very sympathetic. In fact, she evidently qualifies for WLS also but her insurance won't cover it, so we had an interesting talk. She said that out of about 40 employers on her list for Alliance, less than 5 won't cover WLS. Anne Arundel Medical Center, my husband's employer, being one of them. She also said that the reason they won't cover it is, most likely, because it's not a procedure they provide at their hospital. So, because I have to go somewhere else to have it done, they won't cover it. How insane is that?
My options now are A) Self pay, which isn't an option unless we win the lottery or someone decides to give me $25,000 or 2) find a job who's insurance covers WLS. As I said, I'm a stay at home mom with 15 month old twins. Hubby works full time. There's really nothing I can do, full time, and have child care.
So, once again, I guess it's the end of the road. Maybe in a few years when the kids go to school and I can work it will be possible. I was so sure I was set this time. I figured I was about 2 months away from having everything done and being able to submit everything for approval. Now I'm just SOL. There's nothing I can do. 
My employer was even willing to purchase the rider policy to cover WLS but our insurance company wouldn't sell it to us. End of the road #1.
Sicne that time I got pregnant, had twins, became a stay at home mom and hubby got a new job, with different insurance. I figured, GREAT, he's working for a hospital.Obivously not a small business so WLS would be covered. But, just to be sure, and before getting started and being disappointed again, I called to make sure. Yep, Alliance PPO coveres WLS, if it's deemed medically necessary.
Once again I begin the process. I've completed my 6 month doctor supervised diet. Picked a surgeon and had my initial consult. Had my appointment set to see his nutritionalist.
Today the nutritionalist office called to tell me that my policy didn't cover nutrition counseling. Not a big deal. I sort of already knew that and figured I'd have to pay out of pocket to see her. Then, she went on to say she called my insurance company just to be sure and she was told I wasn't covered for WLS at all.
How can that be? Alliance covers the procedure. I called to make sure. My husband works for a hospital, in Maryland. How can they not cover it? Turns out that however their insurance is set up they have to follow federal law. Not Maryland law. The hospital itself CHOSE not exclude WLS from it's coverage. Someone actually sat down and made the decision NOT to include WLS in their coverage. They'll cover treatment if I have a heart attack. They'll cover treatment for diabetes. They'll cover testing and treatment for sleep apnea. But they won't cover the surgery that can prevent, or greatly reduce the risk of, those same problems. The woman I spoke with at the insurance was very sympathetic. In fact, she evidently qualifies for WLS also but her insurance won't cover it, so we had an interesting talk. She said that out of about 40 employers on her list for Alliance, less than 5 won't cover WLS. Anne Arundel Medical Center, my husband's employer, being one of them. She also said that the reason they won't cover it is, most likely, because it's not a procedure they provide at their hospital. So, because I have to go somewhere else to have it done, they won't cover it. How insane is that?
My options now are A) Self pay, which isn't an option unless we win the lottery or someone decides to give me $25,000 or 2) find a job who's insurance covers WLS. As I said, I'm a stay at home mom with 15 month old twins. Hubby works full time. There's really nothing I can do, full time, and have child care.
So, once again, I guess it's the end of the road. Maybe in a few years when the kids go to school and I can work it will be possible. I was so sure I was set this time. I figured I was about 2 months away from having everything done and being able to submit everything for approval. Now I'm just SOL. There's nothing I can do. 
Hi Tina,
I'm sorry to hear your news! Don't give up the fight though. In the mean time there is a 'non op' board here on OH and you may find support there and of course you are always welcome here on the Maryland board. Just because you have an issue with insurance doesn't exclude you from our support and caring. Please keep in touch with us.
Hugs, Mo
Tina,
I am terribly sorry to hear about your ordeal. How frustrated you must be feeling, after all that preparation. I have no information on alternatives except for a comment my doctor made once when I had an insurance foul up. It may be a good idea to look into the university of maryland medical system. They apparently can be helpful in cases like yours. I hope I am not giving false hope. Just wanted to pass it on IN CASE there may be something for you there.
Good luck,
Julie
Rejoicing 2B free
on 7/15/06 1:54 pm - southern states
on 7/15/06 1:54 pm - southern states
Tina, You might want to look into your insurance coverage further. Being as your insurance is thru hubbys job at the hospital and the hospital employs more than 50 employees in the ins policy there may be cause to overturn the decision due to Maryland laws about exclusions via appeal. A lady who is Dr. Greene's wls patient Leesa Weiss is very informed about the laws and is on the Maryland Legislative Action Committee and is herself in the law profession. ( look up peers in Maryland and under her name in the Obesity Help list) She explained it all to me when I was pre-op and if you asked her surely she would help you sort thru this maze of insurance. Our insurance was thru a self-insured union with an ironclad exclusion and I had my surgery in DC at GWU with Dr. Paul Lin. DC hospitals offer a huge discount if you self pay prior to surgery. I read Maryland hospitals don't/can't offer discounts. Good luck to you. The road is long and hard but press on and do not give up. God can make a way. Mary
Leesa
on 7/16/06 12:14 am - MD
on 7/16/06 12:14 am - MD
Tina,
I'm the person that Mary wrote to you about in response to your post. (Thank you, Mary; I'm glad you were able to find a way to make your WLS happen.)
The situation you've described is one that I've heard about with regard to other Maryland hospitals, including people who work for the hospitals that do have WLS programs, but where the hospital health plan specifically excludes WLS from its coverage. The type of health plan your husband has through Anne Arundel Medical Center is where the hospital is self-insured, which is an option for employers under the Federal ERISA laws. Because they are using a plan which is provided for under Federal law, it is unlikely that there is a basis for any state jurisdiction where the Maryland Insurance Administration can intervene (although you should still contact the MIA to see if there is some exception or loophole). Under the self-insured plans, the employer is, in effect, the insurer, and the health insurance company, such as Alliance, is merely an administrator of the plan. Alliance hasn't made the decision not to cover the surgery, as you've found, it's the hospital.
You've indicated that Anne Arundel Medical Center doesn't have a WLS program. What you may want to do is find someone in the know in their human resources/benefits office and inquire whether they have any agreements with other local hospitals or medical systems where if an insured cannot obtain certain services from Anne Arundel Medical Center (because they don't provide it in the first place), can they obtain the services at some discount through a reciprocity agreement w/another hospital.
Another option you may want to explore is special financing. There is a firm, Care Credit, http://www.carecredit.com, that provides certain financing packages for specialty surgeries. I don't know what their policy is, or how good the program is, but it may provide you with a way of proceeding.
Best of luck. I hope you can make it happen.
Leesa
MAC-in-MD
on 7/17/06 2:44 am - Stuck in Traffic, MD
on 7/17/06 2:44 am - Stuck in Traffic, MD
Tina,
Call Alliance again, just to be certain. You were told you were covered, and the nutritionist was told you weren't.......so somebody was given the wrong answer. I hopeful that your original answer was the RIGHT one!
Marcia
Most Active
Recent Topics
