Paul's Primer - Employer Exclusions

Here is an overview of what an employer based exclusion is.  These seem to be most common among employers who are self-insured, particularly public sector employers.  Every year employers select the coverage they are going to provide employees for the following year. For most companies this happens in the fall for the next calendar year, though some companies make this coincide with their fiscal year. At that time, they have a number of options at their disposal to either make coverage more complete or less expensive. Typically these are things such as what your copays and deductibles are going to be for your primary physician, specialists, hospital stays, prescriptions, etc. They also at that time decide what percentage of the total premium is going to be designated as the employee's portion and what amount they are going to pay as a provided benefit. There are certain medical processes that can be fairly expensive. WLS is one of those. A nother that is often classified similarly is in-patient drug rehabilitation (detox).  Organ transplants were often similarly classified in the early days of organ transplantation, and now they are covered routinely. The mechanism varies from insurance company to insurance company. In some, those procedures are treated as a supplement to the basic policy and an extra charge is figured in the premium if the employer wants those services included in the plan. In others, those procedures are treated as a standard part of the plan, but a deduction from the premium is made if the employer wants a less expensive premium and is willing to live with not offering insurance that includes those procedures. In either case it is a decision YOUR EMPLOYER, not the insurance company made to save money by giving you lesser insurance. There are a couple of options to approach your employer on the basis of. One of the services the insurance company offers the employer, particularly self insured (ERISA) employers, is to bear the brunt of your ire and to shield them from your outrage. Getting mad at the insurance company for what your employer decided is sort of like if your parents said they would buy you a car for graduation, you told them to make sure it was a corvette with a sunroof and a CD player, and you get to the car dealer and it is a four door Taurus with an AM/FM radio.  Would you get mad at the car dealer for what your parents bought?  Same thing here. There are some things you can do instead of just give up. 1) If you have a union, you need to have them take up the issue of insurance coverage exclusions in negotiations. 2) You can approach the employer about offering both types of coverage and making 100% of the difference in cost for the better insurance part of the employee's portion of the premium, thereby not costing the employer a penny extra. 3) If you and a spouse are each covered individually at work, you may want to decline your employer's coverage and you get a bigger take home check and be covered as a spouse and the spouse take home a bit less because the cost of a higher premium is taken out of the spouse's paycheck. This can typically only be done at open enrollment time. 4) If WLS used to be covered, and all the executives needing it got it, or all the owner's relatives who needed it got it, or all the males got it, or some other definable group, and then the exclusion was put on, you may have the basis of a Federal EEOC complaint (equal employment opportunity commission). This you would need to consult an employment law attorney about. The key is if there is a definable group that got it and definable groups that did not (men vs. women, execs vs. employees). Generally even if the policy is not changed, you may be able to negotiate your surgery being paid for as your settlement of the complaint. 5) You can always suggest they take part of those part of their premium savings and help pay for your surgery. 6) Your last resort is to seek employment with an employer that offers more comprehensive benefits.

Thanks.  I'm going to pin this so we dont lose it and others can see it.