MMO and EOB Out of pocket cost

Hey All, I just wanted to let you know about the EOB's I just got. For my pre-op and post op comes to about $38,000.00 I've paid less than $200.00. I've said it before and I'll say it again. Hubby might not make as much as some, but we have GREAT medical insurance. I really like MMO.

That is awesome, Robin! My husband has MMOH too and we've really been happy with it. They've paid 100% of most everything we've claimed. For my surgery I had to pay $1500 out of pocket because I used a doctor out of network, but they paid the hospital bill in full. I feel the same as you, my husband's salary is low compared to others, but the insurance makes up for it. ~Jessi

Robin: That's great! My employer switched from MMO to Anthem BC/BS this month. Unfortunately for me, Anthem has an exclusion for bariatric surgery. Thankfully, my husband can get MMO through his work during open enrollment this May and by July I'll have MMO back! Yipee! I've already called and they told me right off the bat that all I will need is the five year history and the psychological evaluation. Hopefully, the State of Ohio won't switch and drop MMO, too. I'm exploring to see if I can get on before the open enrollment, but I've been overweight all my life. I can wait another six months!

You need to check with Anthem again. I ran into the same situation, in which I was initially led to believe it wasn't covered. Get the procedure and diagnostic codes for the procedure (I don't have them handy, but probably can be found here someplace) and ask specifically if they are covered. My Anthem policy has an exclusion for WLS too, however anyone that is morbidly obese is excluded from the exclusion. Most customer service reps don't understand the differences and just say no when asked about WLS. Anthem just paid for my WLS in October, along with many others here.

Bob: Thanks for letting me know. I did not specifically ask if it was covered if you are morbidly obese. Nice to know that there may be an exclusion to the exclusion! I will try calling again and see what response I get. The customer service rep I said that when the contract was renewed, that it was excluded. I took it to mean that if I had the surgery on 12/31/03 it would have been covered, but not 1/1/04. I'm not going to give up! Thanks for the advice!! CJ

will anthem ppo was very rude to me and said no even to my HR person. They said no no no i went to a surgon and anthem will not pay for the consultation either what a drag

Sorry to hear about your troubles. Anthem by default doesn't pay for any of the consultations and/or the pysch exams. The other exams are usually paid since they have other valid medical diagnosis. However, in most of the cases that I'm aware of, including myself, Anthem did pay after the fact if the consultation resulted in a diagnosis that indicated that WLS was medically necessary and you were morbidly obese. They did nothing for me until the pre-determination was filed and approved. Once this occured, Anthem was like dealing with a different company. Approvals are so rare for Anthem (but they do seem to approve MO WLS) that most customer services reps are preprogrammed to just say no. I would then have to politely ask them to look at my approved pre-determination record, then they would become very helpful. Your HR person does have some weight they can throw around, especially around renewal time. They can let Anthem know this is a benefit they want their employees to have. If Anthem doesn't comply, then take the business elsewhere. Getting HR to assist in this manner is going be greatly impacted by the size of company where you work. I would also have them send in writing the specific exclusion. I know some people at other insurance companies have won appeals due to technicalities in the written exclusions. For example, MO is considered medically necessary, where other WLS candidates aren't.