Does anyone have any info...

Does anyone have any information on a Maryland law that says you cannot be denied WLS? I am heading towards a denial, and I want to have information to back up my cause. Thanks.

Christine, Maryland's law has its limits, and applies, really, to a relatively small percentage of its population. First, the employer has to have more than 50 full-time employees, and the contract with the health insurance company has to be one where the controlling law over the contract is in Maryland. There are businesses in Maryland which are based elsewhere in the country and/or have their health insurance contract with a provider located out of the state. In addition, the health insurance plan cannot be self-funded -- which is where the employer assumes the liability of the insurance risk, and the health insurance company is merely the outsourced administrator of the plan. Many union and/or state/local government employee health insurance plans, as are the plans used by hospitals and some very large corporations, are self-funded. Self-funded health insurance plans are creatures of the Federal ERISA laws and, therefore, the state has no jurisdiction over them. Also, small groups -- those employers with fewer than 50 full-time employees, are covered under different state regulations where insurance coverages are standardized by a state agency, under which coverage for treatment of obesity/morbid obesity, including surgery, is specifically excluded. In those situations, the employer may attempt to negotiate a special rider with the health insurance company to include weight loss surgery as a part of the health plan. It's at the employer's option, and it's also at the option of the health insurance company to even agree to underwrite the coverage in the first place. If you can find out some more specifics about your health insurance plan, perhaps we can provide some more specific answers. Leesa Weiss Co-Founder/Co-Chair Maryland Weight Loss Surgery Legislative Action Committee

For those that are denied by their insurers-- why don't they just buy an individual plan from BCBS? I called them I got a rate of $210 per month and they will cover the surgery as long as you are a Maryland resident. After surgery I can drop them if I wish. Melanie...

Thanks for that info, I didnt even know you could do that. Do you have any other info that I could use? I havent been denied yet, but have a feeling that I will. How long do you have to be on the plan before you can even consider the surgery? thanks cathy

I decided to go with this plan when I got laid off from my job and lost my insurance. The rates per month will vary based on your age, county and how many people are on the plan. My co-pays are decent $10/20, it includes mental health and it covers WLS without the requirement of dieting for 6 months. But if you have health insurance already then that might complicate things because of shared costs. My rate is 210 per month. The only other charge is a deductible of 250 per hospitalization. But it beats not having any insurance at all. (HMO Blue Choice) Here's the site to find out your custom rate. (https://www)carefirst.com/eSales/index.jsp or call 1-443-394-6691 or toll-free at 1-866-241-6442 Hope that helps-- Melanie

My husband is self-employed and we have had BC/BS for small group for five years . We had to get it when it was open enrollment, where they take you no matter your health issues. We were denied for the underwriters regular insurance due to my height/weight ratio and high blood pressure. This policy will not cover the surgery. I applied for Mamsi and they had to send to regular underwriters first, which I heard from today I was denied. I was told previously that I could do open enrollment with them in Dec and be covered so I wasn't too worried. I was told today that Maryland law has changed and now there is no open enrollment for self-employed for them or any insurance. So, now I will have to self-pay if I go ahead. I am just sick about this. What is a self-employed person with health issues supposed to do? I looks like there will be no insurance available to them at all. I can keep my current insurance but it will not cover the surgery or possible complications if they arise. If anyone has any advice or comments on this I would love to hear them or if you have self-paid how did that work out for you and did you have complications that your insurance did cover? Thanks

My husband works for a construction company and has a small group policy, but I am sure that they have more than 50 employees. When I called (MAMSI) they said that the decision is made on a case by case basis. Do you think that means that it wont be covered? They said that I need a 6 month doctor supervised weight loss and a psych eval before even considering according to my surgeons office Thanks Cathy

Cathy, There are a few "quirks" in the Maryland law. First, if the company once was under 50 full-time employees, and now has grown, but they haven't changed the underlying health plan insurer since they've topped the 50 FT employee limit, they may still have a small group policy, and can maintain it until such time as they change insurance companies. Second, if the health plan is through a union-based plan, it may be self-funded and, therefore, not subject to the jurisdiction of the Maryland law. In either event, if the WLS coverage is through a rider to the policy, and the policy is not subject to the Maryland law, the insurance company may have more discretion they're permitted to exercise in determining qualifications for "medical necessity." The 6-month supervised weight loss plan and psych evaluation are becoming standard requirements for approval of WLS. The State Task Force established by the Maryland General Assembly has recommended that the 6-month supervised weight loss plan be made a bit more flexible with alternative ways of achieving the same goal. However, right now, that's what it is, is a recommendation, and the Maryland Insurance Administration has been tasked to establish standard criteria for approval for WLS under the Maryland statute -- that is, for situations when the statute is applicable. If the statute doesn't apply, it's up to the insurance company to establi****s own criteria, assuming WLS is even included in the plan in the first place. Leesa

Cathy, I had my surgery under Mamsi Optimum Choice 2 months ago. I did the 6 month required supervised diet and once the surgeon submitted the paperwork I was approved in 2 days. When I called Mamsi in the begining inquiring about the surgery first they said it was not a covered benefit. The next time I called back I was told the same thing and then told it was Maryland Mandated since I didn't fall into the small group exclusion. If they told you on a case by case basis then more than likely you are not excluded and will be approved once you've completed the required diet and psych evaluation. Good luck with you wl journey, Denise