"50 employees" question

Does anyone know whether this means the employer must have more than 50 employees signed up for the health-insurance plan or just more than 50 employees period? My employer has 62 employees, and yet I was denied based on the "50 employees" exclusion. I'm trying to brainstorm reasons why. There's also the possibility that my company is corrupt and lying about its "small business" status (claiming it has fewer than 50 employees, when it has 62). I wonder if any legal action could be taken to force coverage. Anyone else had to battle with this? Thanks in advance.

Liz, I have the same problem. There has to be 50 employee's signed up and using the same insurance as you. If not you have a small group which is considered ( MSGR ) Maryland Small Group Reform. The state of Maryland mandated this exclusion from all small groups. I have been fighting with my insurance company for 2 years. To have the Lap-Band surgery here in Maryland the average cost is $ 24,000.00. I have decided to go to Mexico. I have my surgery 12/9/05. If this is an option for you the cost is $ 8200.00 all included except airfare. You can finance part of this with the doctor. Read my profile for the info on my doctor. Trust me it's safe , again keep in mind I have been researching this for 2 years before I made my decision. Below are the links to my doctor and to a site for Tracy she is the reason I decided to go to Mexico. Also if you read my site it will tell you about a fill doctor here in Maryland you can use. I hope this helps. Happy Holidays, Donna T http://www.mexicolapband.com/index1.php http://www.tracyslapband.com/index.htm

Liz, The small business status is based on the total number of full-time employees, not just the number of employees signed up for health insurance. However, there are perhaps a few additional issues which may/may not impact your situation. It's my understanding that if the employer, at one time, had fewer than 50 full-time employees, but the number of employees has grown to more than 50, it may retain its small business status (and, thus, the exemption from mandatory inclusion of WLS surgery in its health insurance) if it has not changed carriers, that is, it's the same health insurance company and policy/plan as it had before it had more than 50 employees. Another factor for you to investigate is whether the health insurance plan for your employer is considered "self-insured". In this situation, it doesn't matter whether there are more or less than 50 full-time employees. A self-insured health plan is where, technically, the employer becomes the health insurer and has the liability for providing coverage, and the health insurance company is actually out-sourced to administer the health plan, but has no liability as an insurer. Self-insured health insurance is a creation of the Federal ERISA laws, and therefore, is outside the jurisdiction of the Maryland laws. There is no requirement for self-insured health plans to provide WLS, although some choose to do so; it's totally at the option of the employer. Hope this helps you to better investigate your options. Good luck. Leesa

"It's my understanding that if the employer, at one time, had fewer than 50 full-time employees, but the number of employees has grown to more than 50, it may retain its small business status (and, thus, the exemption from mandatory inclusion of WLS surgery in its health insurance) if it has not changed carriers, that is, it's the same health insurance company and policy/plan as it had before it had more than 50 employees." That's outrageous! Thank you, both, so much for your thorough and informative replies. I didn't expect such quick responses. I'll do a bit more snooping just to verify that there's no chance with insurance, and then I'll self-pay. I've been imagining my life post-surgery for so long that I just can't throw that all away now. Thanks, and good luck!

Liz, I agree that it's outrageous. If, after your further investigation, you still believe there's a basis for your being covered (or should be covered) by your employer's health insurance, go through the appeal process and, if necessary, contact the Maryland Insurance Commission. They've got some good people there who are familiar with the ins and outs of the law and its applications. I do empathize with you. I had to self-pay, but for different reasons. I live in Maryland, pay taxes to the state, and all of my physicians are in Maryland. However, I work in Washington, DC for a private employer. DC has no law mandating WLS, and MAMSI successfully held their ground through my two appeals. They didn't seem to care whether I could drop dead the next day w/o the surgery, they wouldn't pay. Now, of course, if I had stomach cancer, and I needed the same surgery to remove the cancer, THAT they would have paid for! Leesa

I've learned from CareFirst BlueChoice that, indeed, as long as a company had fewer than 50 employees when it negotiated its insurance contract, they can retain that plan as long as they want even if they grow to have more employees. And of course there's no incentive for them to renegotiate it, because everyone's premiums would go up. Sneaky.