Another Insurance question

Hello!

I started on the WLS journey last year, but my insurance policy had an exclusion. I work for a small business. Well I asked the woman who handles our insurance if we could buy a policy that doesn't have WLS as an exclusion. She told me that according to our insurance broker, Maryland passed a mandate stating that all policys starting July 1, 2009 must cover WLS (if you fit the criteria) for all policies, not just group policies.

Our open enrollement is starting now and I will have to renew my insurance for Dec 1.

Has anyone had any experience with being approved for surgery since this mandate passed? I  just don't want to get my hopes up again.

thanks!

Sara

I am aware of the mandate.  However, the change was not that insurance company must offer it.. it was that employers must include it in their packages.  Who is the insurance provider that you will be using?

Here is what you need to remember.  Let's use Aetna as an example. 

Aetna offers every kind of coverage that is available.  However, your company creates a contracted plan with them that offers what your company is willing to pay for and what they're legally mandated to provide.  Because your company was small, prior to the new mandate, even though Aetna have WLS coverage, your company was not mandated to include it in their package.  My company, because of its size, was already mandated to included it.

So, continuing with the example of Aetna, if that were your provider, the criteria for getting approved would be the same criteria that Aetna has always had  and your experience will be what is typical of Aetna (or whatever plan you're actually going to be using.)

Ultimately, your chances of being approved are exactly what they were to start with... which is based on your weight, BMI, prior weightloss attempts, psych eval and co-morbidity factors.

Hope this helps.. Good Luck!

I did not have insurance issues honey but I wanted to say GOOD LUCK and WELCOME TO  THE MARYLAND BOARD ;o) And I see Pam has given you some great advice. She is AMAZING!! (((Hugs)))

Thanks for the advice!

I have Carefirst Bluechoice HMO. I asked for documentation stating that our insurance will include the coverage for WLS from the woman who handles our insurance. Hopefully it work out for this go around!.

I am well aware of all the hoops I need to jump through but my doctors and I really want for me to have WLS.

for the record:
BMI: 49.6
I also have type 2 diabetes, high blod pressure and sleep apnea.

Thanks for the support. This forum is really great!

Sara
                  

sara.. my bmi was 48 and i also had type 2 diabetes and sleep apnea.  my approval sailed through.  i'm healthier than ever.  the diabetes was "gone" before i left the hospital and my apnea was gone in less than three months.  good luck to you!

I have Empire Blue Cross Blue Shield, but I also work for a very large company who covered WLS before the mandate went through.  I know with Blue Cross, my approval was a very easy process, but I also found a surgeon who made it an easy process.  At my first appointment, they called on my behalf and got exactly what was needed to get my approval through - a mandatory letter of medical necessity from my PCP (I actually got two - one from my PCP and one from my cardiologist), a psych consults (not covered by insurance) and 6 months of supervised medical weight loss (or 2 separate instances of a place like Weigh****chers, Jennie Craig, etc).  My surgeon had additional requirements on top of that - Cardiac clearance (with stress test), scan of my lower extremities to make sure I didn't have any blood clots hanging around), sleep test, blood work, pulmonary function test, etc.  I got all my paperwork together, documented everything, and voila - I got my information to the surgeon on 10/21 and was approved on 10/23.

My bmi is over 50, I have diabetes, apnea, CAD, high cholesterol and high blood pressure.  I'm hoping by next week, by the time I leave the hospital, the diabetes is gone baby gone.

Hey Bernice!!!  You had more pre-surgical testing than I did, but I remember my surgeon's nurse telling me that some people have to have more testing based on their co-morbidity factors.  i'm so excited for you.  i cannot wait to see you move through your journey.  they are moving me to the 13th floor today.  i'll be in the area in front of the kitchen.  come find me when you get back to work and let me know how it's going.  i'm always there if i can help in any way.

Hi Pam!  If I am correct, you are the wonderful new friend I met and sat next to at dinner on Sunday night?  I'm just guessing because you didn't look anything like Pooh at the Woodfire.

that was me!!  i'm not quite as stuffed with fluff as i used to be.  :)  however, a lot of my friends do actually call me pooh!  it was very nice to meet you.  i don't make it to too many events and i had pretty much stopped posting for months.  sometimes you just need a break from social networking. ha ha

Pam - most of my pre-reqs were my surgeon's pre-req's.  The only three BCBS required were the psych consult, the 6 mos weight loss, and the letter of medical necessity.  Dr. McKenna required everything else because he's a stickler and doesn't want any surprises when he opens you up.

And 13th floor!  Your moving up!  I'll definitely come find you when I get back!  I'm still on 16 - two cubes away from the ladies room. 

How long were you out?