Sample Insurance Letters? Maryland WLS coverage law??
Does anyone know of any sample letters to use as a basis for writing one's insurance company?
I want to know from UHC in writing:
1. Will they cover the procedure in the USA (not likely, at my BMI, and from what I've already learned)
2. If I go to Mexico (very likely) and then later have complications, will insurance cover it.
and if they won't... then I have to contact Tricare.
Also, I've seen several references here to a law regarding WLS in Maryland - but so help me, I've been unable to actually FIND the law. Can anyone point me in the right direction??
Thanks in advance!
Sheri (getting more and more anxious to have the procedure!!)
I want to know from UHC in writing:
1. Will they cover the procedure in the USA (not likely, at my BMI, and from what I've already learned)
2. If I go to Mexico (very likely) and then later have complications, will insurance cover it.
and if they won't... then I have to contact Tricare.
Also, I've seen several references here to a law regarding WLS in Maryland - but so help me, I've been unable to actually FIND the law. Can anyone point me in the right direction??
Thanks in advance!
Sheri (getting more and more anxious to have the procedure!!)
I've been fat, and I've been thin - and thin is better.
There is a better way. --Alaine of Lyndar
--------------------------
HW: 234. SW: 228 (18 June 2015). GW: 137. Specs: 50ish, 5'4"
Sheri -
Not to dissuade you from posting here about ANY issues, I thought you might find the Insurance Forum more helpful for this particular issue.
http://www.obesityhelp.com/forums/insurance/
Good luck!!
Tia
Not to dissuade you from posting here about ANY issues, I thought you might find the Insurance Forum more helpful for this particular issue.
http://www.obesityhelp.com/forums/insurance/
Good luck!!
Tia
Ahah, Tia, thanks- I'll check it out -didn't know that forum existed.. figured Maryland was the place to look it up!
Thanks!
Sheri
Thanks!
Sheri
I've been fat, and I've been thin - and thin is better.
There is a better way. --Alaine of Lyndar
--------------------------
HW: 234. SW: 228 (18 June 2015). GW: 137. Specs: 50ish, 5'4"
Below is the maryland state law on surgical treatment of morbid obesity. If you have UHC find out what state governs it. I live here md and my insurance is governed by the California Department of Insurance.
SENATE BILL 522 Unofficial Copy 2001 Regular Session C3 1lr0385 SB 496/00 - FIN CF 1lr0386 ____________________________________________________________________________________ By: Senators Hoffman and Hollinger, Hollinger, Bromwell, Dorman, Astle, DeGrange, Della, Exum, Hafer, Hooper, Kelley, Roesser, and Teitelbaum Introduced and read first time: February 2, 2001 Assigned to: Finance _____________________________________________________________________________________ Committee Report: Favorable with amendments Senate action: Adopted Read second time: March 21, 2001 _____________________________________________________________________________________ CHAPTER_______ 1 AN ACT concerning 2 Health Insurance - Treatment of Morbid Obesity 3 FOR the purpose of requiring certain insurers, nonprofit health service plans, health 4 maintenance organizations, and managed care organizations, and carriers to 5 provide coverage for the expenses incurred by certain obese patients for certain 6 surgical treatment under certain cir****tances; authorizing certain benefits to 7 be provided through a managed care system; of morbid obesity; requiring the 8 coverage of morbid obesity to be provided to the same extent as for other 9 medically necessary surgical procedures; defining certain terms; providing for 10 the application of this Act; and generally relating to coverage of expenses for 11 surgical treatment of morbid obesity under health insurance. 12 BY adding to 13 Article - Insurance 14 Section 15-837 15 Annotated Code of Maryland 16 (1997 Volume and 2000 Supplement) 17 BY adding to 18 Article - Health - General 19 Section 19-706(rr) 20 Annotated Code of Maryland 21 (2000 Replacement Volume) 2 SENATE BILL 522 1 Preamble 2 WHEREAS, Obesity is a significant health problem affecting hundreds of 3 thousands of Maryland residents; and 4 WHEREAS, Severe or morbid obesity increases the mortality rate more than 5 threefold, causes physical and emotional disability, is often associated with comorbid 6 conditions compounding its adverse impact on longevity and quality of life, and is 7 amenable to established surgical treatment; and 8 WHEREAS, Like other chronic diseases, obesity is caused or aggravated by 9 many factors including genetics, behavior, metabolism, and environment, certain 10 therapeutic interventions can alter its course and severity, and therefore, obesity 11 should be treated for purposes of insurance like other medical conditions; and 12 WHEREAS, Health insurance policies commonly exclude coverage for the 13 treatment of obesity, even when severe or morbid and complicated by comorbid 14 conditions; now, therefore, 15 SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF 16 MARYLAND, That the Laws of Maryland read as follows: 17 Article - Insurance 18 15-837. 19 (A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS 20 INDICATED. 21 (2) "BODY MASS INDEX" MEANS A PRACTICAL MARKER THAT IS USED TO 22 ASSESS THE DEGREE OF OBESITY AND IS CALCULATED BY DIVIDING THE WEIGHT IN 23 KILOGRAMS BY THE HEIGHT IN METERS SQUARED. 24 (3) "MANAGED CARE SYSTEM" MEANS A METHOD THAT AN INSURER, 25 NONPROFIT HEALTH SERVICE PLAN, OR HEALTH MAINTENANCE ORGANIZATION 26 USES TO REVIEW AND PREAUTHORIZE A TREATMENT PLAN THAT A HEALTH CARE 27 PRACTITIONER DEVELOPS FOR A COVERED PERSON USING A VARIETY OF COST 28 CONTAINMENT METHODS TO CONTROL UTILIZATION, QUALITY, AND CLAIMS. 29 (4) (3) "MORBID OBESITY" MEANS A BODY MASS INDEX THAT IS: 30 (I) GREATER THAN 40 KILOGRAMS PER METER SQUARED; OR 31 (II) EQUAL TO OR GREATER THAN 35 KILOGRAMS PER METER 32 SQUARED WITH COMORBIDITY OR COEXISTING MEDICAL CONDITIONS, INCLUDING 33 HYPERTENSION, CARDIOPULMONARY CONDITIONS, SLEEP APNEA, OR DIABETES. 34 (B) THIS SECTION APPLIES TO: 3 SENATE BILL 522 1 (1) INSURERS AND NONPROFIT HEALTH SERVICE PLANS THAT PROVIDE 2 HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS ON AN 3 EXPENSE-INCURRED BASIS UNDER HEALTH INSURANCE POLICIES OR CONTRACTS 4 THAT ARE ISSUED OR DELIVERED IN THE STATE; AND 5 (2) HEALTH MAINTENANCE ORGANIZATIONS THAT PROVIDE HOSPITAL, 6 MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS UNDER CONTRACTS 7 THAT ARE ISSUED OR DELIVERED IN THE STATE; AND 8 (3) MANAGED CARE ORGANIZATIONS, AS DEFINED IN § 15-101 OF THE 9 HEALTH - GENERAL ARTICLE; AND 10 (4) CARRIERS THAT OFFER HEALTH BENEFIT PLANS UNDER TITLE 15, 11 SUBTITLE 12 OF THE INSURANCE ARTICLE. 12 (C) SUBJECT TO SUBSECTION (E) OF THIS SECTION, AN ENTITY SUBJECT TO 13 THIS SECTION SHALL PROVIDE COVERAGE FOR THE EXPENSES INCURRED BY A 14 PATIENT WITH MORBID OBESITY FOR ESTABLISHED SURGICAL TREATMENT IF: 15 TREATMENT OF MORBID OBESITY THROUGH GASTRIC BYPASS SURGERY OR 16 ANOTHER SURGICAL METHOD THAT IS: 17 (1) RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH AS 18 EFFECTIVE FOR THE LONG-TERM REVERSAL OF MORBID OBESITY; AND 19 (2) CONSISTENT WITH CRITERIA APPROVED BY THE NATIONAL 20 INSTITUTES OF HEALTH. 21 (1) ALL NONSURGICAL MEDICAL THERAPIES, AS DETERMINED BY THE 22 PHYSICIAN, HAVE FAILED; AND 23 (2) THE BODY MASS INDEX OF THE PATIENT EXCEEDS: 24 (I) 40 KILOGRAMS PER METER SQUARED; OR 25 (II) 35 KILOGRAMS PER METER SQUARED IN THE PRESENCE OF 26 HYPERTENSION, DIABETES, HIGH LDL CHOLESTEROL, LOW HDL CHOLESTEROL, 27 HYPERTRIGLYCERIDEMIA, SLEEP-APNEA SYNDROME, OSTEOARTHRITIS, OR OTHER 28 MEDICAL CONDITIONS CONSIDERED BY A PHYSICIAN POTENTIALLY REMEDIABLE BY 29 SIGNIFICANT WEIGHT REDUCTION. 30 (D) AN ENTITY SUBJECT TO THIS SECTION SHALL PROVIDE THE BENEFITS 31 REQUIRED UNDER THIS SECTION TO THE SAME EXTENT AS FOR ANY OTHER 32 MEDICAL CONDITION MEDICALLY NECESSARY SURGICAL PROCEDURES UNDER THE 33 ENROLLEE'S OR INSURED'S CONTRACT OR POLICY WITH THE ENTITY. 34 (E) AN ENTITY SUBJECT TO THIS SECTION MAY PROVIDE THE BENEFITS 35 REQUIRED UNDER THIS SECTION THROUGH A MANAGED CARE SYSTEM. 4 SENATE BILL 522 1 Article - Health - General 2 19-706. 3 (RR) THE PROVISIONS OF § 15-837 OF THE INSURANCE ARTICLE APPLY TO 4 HEALTH MAINTENANCE ORGANIZATIONS. 5 SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 6 policies, contracts, and health benefit plans issued, delivered, or renewed in the State 7 on or after October 1, 2001. 8 SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 9 October 1, 2001.
SENATE BILL 522 Unofficial Copy 2001 Regular Session C3 1lr0385 SB 496/00 - FIN CF 1lr0386 ____________________________________________________________________________________ By: Senators Hoffman and Hollinger, Hollinger, Bromwell, Dorman, Astle, DeGrange, Della, Exum, Hafer, Hooper, Kelley, Roesser, and Teitelbaum Introduced and read first time: February 2, 2001 Assigned to: Finance _____________________________________________________________________________________ Committee Report: Favorable with amendments Senate action: Adopted Read second time: March 21, 2001 _____________________________________________________________________________________ CHAPTER_______ 1 AN ACT concerning 2 Health Insurance - Treatment of Morbid Obesity 3 FOR the purpose of requiring certain insurers, nonprofit health service plans, health 4 maintenance organizations, and managed care organizations, and carriers to 5 provide coverage for the expenses incurred by certain obese patients for certain 6 surgical treatment under certain cir****tances; authorizing certain benefits to 7 be provided through a managed care system; of morbid obesity; requiring the 8 coverage of morbid obesity to be provided to the same extent as for other 9 medically necessary surgical procedures; defining certain terms; providing for 10 the application of this Act; and generally relating to coverage of expenses for 11 surgical treatment of morbid obesity under health insurance. 12 BY adding to 13 Article - Insurance 14 Section 15-837 15 Annotated Code of Maryland 16 (1997 Volume and 2000 Supplement) 17 BY adding to 18 Article - Health - General 19 Section 19-706(rr) 20 Annotated Code of Maryland 21 (2000 Replacement Volume) 2 SENATE BILL 522 1 Preamble 2 WHEREAS, Obesity is a significant health problem affecting hundreds of 3 thousands of Maryland residents; and 4 WHEREAS, Severe or morbid obesity increases the mortality rate more than 5 threefold, causes physical and emotional disability, is often associated with comorbid 6 conditions compounding its adverse impact on longevity and quality of life, and is 7 amenable to established surgical treatment; and 8 WHEREAS, Like other chronic diseases, obesity is caused or aggravated by 9 many factors including genetics, behavior, metabolism, and environment, certain 10 therapeutic interventions can alter its course and severity, and therefore, obesity 11 should be treated for purposes of insurance like other medical conditions; and 12 WHEREAS, Health insurance policies commonly exclude coverage for the 13 treatment of obesity, even when severe or morbid and complicated by comorbid 14 conditions; now, therefore, 15 SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF 16 MARYLAND, That the Laws of Maryland read as follows: 17 Article - Insurance 18 15-837. 19 (A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS 20 INDICATED. 21 (2) "BODY MASS INDEX" MEANS A PRACTICAL MARKER THAT IS USED TO 22 ASSESS THE DEGREE OF OBESITY AND IS CALCULATED BY DIVIDING THE WEIGHT IN 23 KILOGRAMS BY THE HEIGHT IN METERS SQUARED. 24 (3) "MANAGED CARE SYSTEM" MEANS A METHOD THAT AN INSURER, 25 NONPROFIT HEALTH SERVICE PLAN, OR HEALTH MAINTENANCE ORGANIZATION 26 USES TO REVIEW AND PREAUTHORIZE A TREATMENT PLAN THAT A HEALTH CARE 27 PRACTITIONER DEVELOPS FOR A COVERED PERSON USING A VARIETY OF COST 28 CONTAINMENT METHODS TO CONTROL UTILIZATION, QUALITY, AND CLAIMS. 29 (4) (3) "MORBID OBESITY" MEANS A BODY MASS INDEX THAT IS: 30 (I) GREATER THAN 40 KILOGRAMS PER METER SQUARED; OR 31 (II) EQUAL TO OR GREATER THAN 35 KILOGRAMS PER METER 32 SQUARED WITH COMORBIDITY OR COEXISTING MEDICAL CONDITIONS, INCLUDING 33 HYPERTENSION, CARDIOPULMONARY CONDITIONS, SLEEP APNEA, OR DIABETES. 34 (B) THIS SECTION APPLIES TO: 3 SENATE BILL 522 1 (1) INSURERS AND NONPROFIT HEALTH SERVICE PLANS THAT PROVIDE 2 HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS ON AN 3 EXPENSE-INCURRED BASIS UNDER HEALTH INSURANCE POLICIES OR CONTRACTS 4 THAT ARE ISSUED OR DELIVERED IN THE STATE; AND 5 (2) HEALTH MAINTENANCE ORGANIZATIONS THAT PROVIDE HOSPITAL, 6 MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS UNDER CONTRACTS 7 THAT ARE ISSUED OR DELIVERED IN THE STATE; AND 8 (3) MANAGED CARE ORGANIZATIONS, AS DEFINED IN § 15-101 OF THE 9 HEALTH - GENERAL ARTICLE; AND 10 (4) CARRIERS THAT OFFER HEALTH BENEFIT PLANS UNDER TITLE 15, 11 SUBTITLE 12 OF THE INSURANCE ARTICLE. 12 (C) SUBJECT TO SUBSECTION (E) OF THIS SECTION, AN ENTITY SUBJECT TO 13 THIS SECTION SHALL PROVIDE COVERAGE FOR THE EXPENSES INCURRED BY A 14 PATIENT WITH MORBID OBESITY FOR ESTABLISHED SURGICAL TREATMENT IF: 15 TREATMENT OF MORBID OBESITY THROUGH GASTRIC BYPASS SURGERY OR 16 ANOTHER SURGICAL METHOD THAT IS: 17 (1) RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH AS 18 EFFECTIVE FOR THE LONG-TERM REVERSAL OF MORBID OBESITY; AND 19 (2) CONSISTENT WITH CRITERIA APPROVED BY THE NATIONAL 20 INSTITUTES OF HEALTH. 21 (1) ALL NONSURGICAL MEDICAL THERAPIES, AS DETERMINED BY THE 22 PHYSICIAN, HAVE FAILED; AND 23 (2) THE BODY MASS INDEX OF THE PATIENT EXCEEDS: 24 (I) 40 KILOGRAMS PER METER SQUARED; OR 25 (II) 35 KILOGRAMS PER METER SQUARED IN THE PRESENCE OF 26 HYPERTENSION, DIABETES, HIGH LDL CHOLESTEROL, LOW HDL CHOLESTEROL, 27 HYPERTRIGLYCERIDEMIA, SLEEP-APNEA SYNDROME, OSTEOARTHRITIS, OR OTHER 28 MEDICAL CONDITIONS CONSIDERED BY A PHYSICIAN POTENTIALLY REMEDIABLE BY 29 SIGNIFICANT WEIGHT REDUCTION. 30 (D) AN ENTITY SUBJECT TO THIS SECTION SHALL PROVIDE THE BENEFITS 31 REQUIRED UNDER THIS SECTION TO THE SAME EXTENT AS FOR ANY OTHER 32 MEDICAL CONDITION MEDICALLY NECESSARY SURGICAL PROCEDURES UNDER THE 33 ENROLLEE'S OR INSURED'S CONTRACT OR POLICY WITH THE ENTITY. 34 (E) AN ENTITY SUBJECT TO THIS SECTION MAY PROVIDE THE BENEFITS 35 REQUIRED UNDER THIS SECTION THROUGH A MANAGED CARE SYSTEM. 4 SENATE BILL 522 1 Article - Health - General 2 19-706. 3 (RR) THE PROVISIONS OF § 15-837 OF THE INSURANCE ARTICLE APPLY TO 4 HEALTH MAINTENANCE ORGANIZATIONS. 5 SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 6 policies, contracts, and health benefit plans issued, delivered, or renewed in the State 7 on or after October 1, 2001. 8 SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 9 October 1, 2001.
Your welcome and I also have some other information that my be of help if you need it.
When I filed my appeal with my insurance company I also sent a complaint to the California Department of Insurance and to Obesity Law and Advocacy center in California. I didn't show all my aces to the insurance co just in case I need to request an independent medical review.
Currenlty my co morbidities are
moderate sleep apnea
diabetes
hi cholerstoral
hypertension
peripheral artery disease
and possible 2 min strokes in the past 6 months
osteoarthritis in my knees
anxity disorder
and BMI of 44.6
height 5''5"
weight 265
bp 150/120 at last drs visit 2 weeks ago
Good luck and if you need anything else let me know
hugs
Zells_lori is"abuddongrose"
Do you have any co-morbids? Diabetes, High BP , sleep apnea?
My BMI was too low, but the comorbidities pushed me over. I had my Primanry care doc of 12+ years write a letter, my endo wrote a letter. and I was approved in 4 days.
Good luck,
Tom
My BMI was too low, but the comorbidities pushed me over. I had my Primanry care doc of 12+ years write a letter, my endo wrote a letter. and I was approved in 4 days.
Good luck,
Tom
People laugh because I'm different, I laugh because they are all the same
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