New to the MD board

Hello, Maryland! I'm from Hagerstown, MD ["the sticks" to a lot of people ;-) ] and I need some advice. I'm employed by a McCorporation which offers Aetna EPO as its insurance. Now, I've heard Aetna, on its own, is solid as far as approvals go. However, I've been hearing more and more that my company is categorically denying all requests for the surgery as, and I quote: "too many people are gaining the weight back" Great. I'm trying to stay positive, but it's difficult. Is it still worth it to go through everything [ie: all the doctor's appointments, surgeon's evals, etc]? Okay, so maybe I phrased that improperly. I would do anything to get this surgery, but have any of you ever run into a situation like this and had it overturned? Another thing I've looked into is paying out of pocket. Again, I would do that if necessary, but I have no idea how to go about starting. Do I get a loan, do I talk to a surgeon who makes the payment arrangements, etc? Any help/suggestions/magical surgeon-proving genies would be much obliged. Again, many thanks just for reading. -Justin

Hey Justin - Yep, living in eastern Baltimore County, Hagerstown is "the sticks" for me! But in a nice way! I just wanted to welcome you to the MD board. Don't be frightened - it's mostly women, although we have some men lurkers/posters sometimes!!! I really wish I could offer some insurance advice, but alas, having an HMO, everything is pretty much decided for you, so I didn't have to do much. Have you called your benefits person? I would, just make an inquiry. As far as out of pocket, I would first pick my surgeon based first on his ability and experience, and then be upfront about your ability/inability to pay. Sorry I couldn't be of more help, I hope everything goes smoothly for you. Teresa

Justin, You need to determine whether your company is "self-insured" which, from what you posted, it sounds that way. If they are self-insured, it means your employer actually is the insurer, and Aetna is merely an outsourced administrator for the insurance, and takes its commands vis-a-vis coverages from the insurer: your employer. Being "self-insured" is an option for employers under Federal ERISA laws, and in most (but not necessarily all) cases, may mean your employer is not subject to Maryland's statute. You can inquire with the Maryland Insurance Administration (in Baltimore) whether, under the terms of your Aetna EPO (if your employer is self-insured), there is any way the state is in a position to exercise its jurisdiction and statutes over your employer to compel them to cover the surgery. If not, then you will have to find a way to have your employer agree to add the coverage. Leesa

Hi Justin, I am in Odenton, Md not the sticks but country for me since I am a NYC gal born and raised there. lol The same here for me I really can't help you in the insurance info I too have a HMO. But I wanted to welcome you to the forums! Wishing you all the best. Cira

Welcome Justin. Hagrstown is the big city compared to Mt. Savage/ Frostburg. That is the area my family has lived since 1970. I currenlty live in Baltimore, however. I have a sister that lives in Hagerstown. I have an HMO and had no problems. I would follow the advice of the posts above concerning insurance. I know where there is a will there is a way. I am one month post op and know I made the best decision. I had RNY. Even though all the testing, poking, and prodding can be tiresome, the end result is fantastic and getting better every day. I'll be able to post my one month loss weds. Keep the faith. Aime

Hi Justin, I'm new, too. I had the same insurance problem you had. My company is self-insured and wouldn't cover the surgery. I had to self-pay. The surgeon's office recommended several options, one being a loan from your bank. I couldn't follow that route because I don't keep much in the bank and would have needed a co-signer, and I wouldn't ask any one to do something like that. I applied at CapitalOne, they have healthcare loans and I was approved in two hours. If your credit is good you can get a really good rate(mine was 7% and a five year loan). Your first step would be finding a surgeon and finding out how much it will cost then apply for that amount. The loan is usually open for two months. There are other options, you just have to look around, maybe the surgeons office can recommend something. Hope this helps.

Good morning Justin, I don't have any insurance help, but would like to say welcome to the board. Best wishes on your WLS journey. Hugs, Mo

Welcome to the Maryland board Justin. Nadine O.