Maryland Law supporting Surgury?

Hi, I'm writing this for my wife who is looking at getting an RNY with Dr Magnuson at JH Bayview Medical Center. She has started the process of finding a doctor/hospital/procedure, but upon contacting our insurrance carrier (CareFirst BlueCross/BlueShield) was told that bariatic surgury was excluded. I looked though the insurrance section and found several refences to a Maryland Law that mandates bariatric surgury for people with large companies. A refrence was made in Apral's profile: http://www.obesityhelp.com/morbidobesity/members/profile.php?N=S1002144847 It was refrenced again in an old CityPaper article: http://www.citypaper.com/news/story.asp?id=9371 My wife called the doctors office this afternoon, as I figured if anyone would be famlier with any state laws on this subject they should be aware of it. Unfortunatley the doc's secretary isn't aware of anything like this. Does anyone have any further information? I've searched on the MD government page, but without specifics, it's like looking for a needle in a hay stack. Any help would be greatly appreciated. tony

Hi Tony, I have Carefirst BC/BS too, but for small group. My husband is self-employed. It is excluded in our policy, as well. Unfortunately, we have to pay for my surgery ourselves. We got a second mortgage to this. I'm sorry I have no answers. I just want to wish you much luck on your quest for insurance coverage and hope that your wife can have the surgery sometime soon. Take care, Wanda

Wanda, Thanks for answering. I'm sorry to hear that you had to go so far for something that insurrance should cover. Here's what we've found so far.... we've been googling all night: http://www.mdinsurance.state.md.us/documents/MarylandsMandatedBenefits01-07.pdf §15-839 Morbid Obesity Coverage for the surgical treatment of morbid obesity that is: (1) recognized by the National Institutes of Health aseffective for the long-term reversal of morbid obesity; and (2) consistent with guidelines approved by the National Institutes of Health. Here's what I found on Lexis/Nexis search for §15-839: http://198.187.128.12/maryland/lpext.dll?f=templates&fn=fs-main.htm&2.0 Source: Maryland Code : INSURANCE : TITLE 15. HEALTH INSURANCE : SUBTITLE 8. REQUIRED HEALTH INSURANCE BENEFITS : § 15-839. Coverage for treatment of morbid obesity. Terms: §15-839 (Edit Search) (Search lexis.com®) § 15-839. Coverage for treatment of morbid obesity. (a) Definitions.- (1) In this section the following words have the meanings indicated. (2) "Body mass index" means a practical marker that is used to assess the degree of obesity and is calculated by dividing the weight in kilograms by the height in meters squared. (3) "Morbid obesity" means a body mass index that is: (i) greater than 40 kilograms per meter squared; or (ii) equal to or greater than 35 kilograms per meter squared with a comorbid medical condition, including hypertension, a cardiopulmonary condition, sleep apnea, or diabetes. (b) Applicability.- This section applies to: (1) insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies or contracts that are issued or delivered in the State; (2) health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State; and (3) managed care organizations, as defined in § 15-101 of the Health - General Article. (c) Coverage - In general.- An entity subject to this section shall provide coverage for the surgical treatment of morbid obesity that is: (1) recognized by the National Institutes of Health as effective for the long-term reversal of morbid obesity; and (2) consistent with guidelines approved by the National Institutes of Health. (d) Extent of coverage for other necessary surgical procedures.- An entity subject to this section shall provide the benefits required under this section to the same extent as for other medically necessary surgical procedures under the enrollee's or insured's contract or policy with the entity. [2001, chs. 493, 736; 2004, ch. 486; 2005, ch. 301.] tony

You can also work for a large company and be stuck with what is called a self-funded policy. I used to work for a large engineering firm with over 1,500 employees all over the east coast. Even though i had PHCS as our provider of services. The policy was self funded (by the company) and according to ERISA regulations (federal guidelines for self funded policies) they can choose to exclude what condition they want as long as no group is allowed to do it.

Thanks for the info Krissandra. We've been scanning through all the old messages all night looking over all the messages looking for information on how to progress with getting this covered. From what we've found, the Maryland law from 2001 states that the coverage is mandatory if medically nessesary and the person covered is with a "large" company. It seems that "large" is defined as more than 50 people. A copy of the bill is available on ObesityLaw : http://obesitylaw.com/getactive.php#statutes My wife works as a teacher for Harford Co public schools, so it seems to me that they're definatly not a small business. Now what we're confused over is people getting denied and having to appeal. Providing you have insurrance with a company with more than 50 employee's in Maryland and the surgury is deemed medically nessesary, how can insurrance companies still say the surgury is excluded and deny people? A couple of posts noted to contact the Maryland Insurrance Commision in baltimore, or the Attornies General's office. If the "law" not being enforced? Is it something that insurrance compaines will deny exists till you have to prove it? tony

Hi Tony, Harford County public schools is definitely not a 'small' company but may fall into the self-insured category. Governmental entities (which the school system is) are more often than not self-funded/insured, but many do also cover WLS despite of being self-funded. Your best bet is to talk to someone in the benefits section in the school system to find out exactly what the policy is. Do not take the insurer's word for it because each time you call the rep you speak to may give you a completely different answer than the previous rep did. Even if a group is self-funded/insured they may still cover it. Also, in a self-funded/insured plan you can appeal to the employer and sometimes have an exception made if necessary. Best wishes to your wife on her WLS journey. Mo

Thanks Mo, I'll have Lisa contact her HR department and get the details on exactly what the contract covers and if it's self funded. The self-funded policy that both you and Krissanda noted is new to both of us, we'll definatly be on the look out for that and ask questions. In the mean time we'll continue on with the required doctors appointments, psyche eval and gathering all the required paperwork. My company is currently getting ready to change insurrance carriers, and that will definatly be a question I'll have for HR. I hesitate to have her jump to my insurrance, as our company is border line "small" and might be a worse position to try to get surgury from. Thank you all for your responses. It's take years for us to get to this stage of decideing on surgury, and I guess we have a lot more to learn. tony

If your insurance company is through a "self insured" business they do not apply to the state mandate. Sorry.

Thanks Heather. I've been looking for information on just what a self insured plan is, since working for a big organization seems to be the opposite of what I considered "self" insured. I gues they mean that the company is the "self" in this instance. Here's the clearest definition I could find is from a Michigan government page: http://www.michigan.gov/cis/0,1607,7-154-10555_12902_35510_35695---,00.html "What is a self-funded health care plan? Self-funded or self-insured health care plans pay benefits from a fund established by an employer or organization. Self-funded plans are not insurance plans and therefore do not come under the authority of the Michigan Office of Financial and Insurance Services. Self-funded health care plans are created under federal law and come under the authority of the federal government." So I guess first off my wife will have to her ask the schools HR person to find out if it is or isn't a self funded/insured plan. Thanks for all the assistance everyone. I feel we're getting a better handle on this... and here I was thinking the agonizing over decideing to choose surgury would be the hard part. tony

More research into how these self insured programs work, looks that they are setup partially to avoid state mandates: http://www.bizjournals.com/milwaukee/stories/2006/02/27/focus4.html "Avoid state mandates Another benefit of self-funding is control over coverage, said Jon Rauser, president of The Rauser Agency, a Milwaukee-based insurance brokerage. Self-funded employers don't have to comply with state mandates that require minimum coverage for things like chiropractic and mental health care. Self-funded employers can decide if they want to pay for mammograms, bariatric surgery, substance abuse and other treatments, Rauser said. " tony