Insurance Help

Hi everyone...still researching the surgery but am certian this is the right thing to do. My boyfriend had it in Feb 06 and has lost over 100lbs. My job is offering open enrollment for insurance....my question is: stay with Kaiser or switch to mamsi optimum choice? I have been reading the insurance boards and have a good idea i should switch to mamsi but would like to check with everyone here? Thanks!

Hi Jamie, I don't have either Kaiser or MAMSI, I had BCBS when I had my surgery almost a year ago. I wish I could help with your question, but in the meantime I wanted to say "Hello" and not to feel shy about posting questions about anything on here. We're all in this together Take Care, Terry

Hi Jamie, Like Terry I have no experience with either insurance, but it's important to see what the coverage of each for the particular company is. Just because it is Kaiser or MAMSI and because someone else had their surgery covered with them doesn't necessarily mean that the company you work with has that same coverage. I'll also second Terry's welcome and please keep posting! Best wishes on your WLS journey. Hugs, Mo

Jamie, Ask your HR/Benefits department for copies of the "Evidence of Coverage" for both MAMSI and Kaiser. As the others have indicated, simply because others have had their WLS surgery covered by both companies doesn't necessarily mean that your policy plan will cover it. First, make certain that your employer's health insurance plan is covered by a Maryland contract. Some businesses with offices located in Maryland are headquartered elsewhere, and their health insurance contract is governed by a contract from another jurisdiction not affected by Maryland statute. Second, if your employer has fewer than 50 full-time employees, check to see whether it has a "rider" in effect with either of the companies to cover WLS. Mamsi has been known to agree to sell the rider to cover WLS; I don't know about Kaiser. (BCBS has been known to refuse to sell the rider.) Third, make certain your employer is not self-insured for its health insurance plan. If it is, Kaiser and Mamsi are only serving as third-party administrators for the plan; the ultimate scope of coverage is dictated by the employer, not the health insurance company. Such health plans are governed by Federal ERISA laws, not state law. If coverage is available under either policy, find out which has the greatest choices of doctors/hospitals. If you're in the Baltimore area, do both plans offer you the option of using Baltimore surgeons/hospitals, or will you have to travel to Silver Spring (Holy Cross/Dr. Brian Cantor) or DC (GW Hospital/Dr. Lin) -- both surgeons/hospitals which, I've heard, work with Kaiser? This isn't necessarily a bad thing, but it may be a consideration in choice of plans. Also, while both plans, I believe, have minimum periods of prior dieting efforts and the like, Kaiser's plan is known to be relatively rigid, where you may have to complete these pre-requisites w/in their system, instead of being able to produce doctor's records (which you may already have been working on). Best of luck in your efforts! Leesa

Jamie; I would look into it if I were you... I too had Kaiser when I started this WLS journey and not to scare you, but my battle with them SUCKED! I had to do this and that, then they changed their stories and I had to do something else. It was a lot of back and forth with them. I am now with MAMSI Optimum Choice since my company was bought. I love MAMSI! Within the matter of 72 hours of switching insurances, I was approved! My surgery is scheduled for August 10th! Hope this helps, if you have any more questions feel free to email me: [email protected] Leslie

I don't know about Kaiser, but I had MAMSI - optimum choice and was approved on the first letter. I will tell you from experience that they typically require (with all their policies) 6 months CONSECUTIVE (advice - see your PCP every 28 days and make sure they document height, weight, BP, and discussions of weight loss attempts) physician weight loss program, a letter of medical neccessity, at least 3 documented comorbites, a psychiatric evaluation (must me on their form), and a cardiatric clearance for surgery. Most of these your surgeon would also require, but MAMSI required it as well. They were very easy to work with and they didn't give me the runaround. Hope that helps, Roni