General Insurance Info

I posted this on the general discussion post and someone suggested I put it here, so here it is.  Good luck with your journey.   Victor Hello, I'm new to this site and forum.  I'm currently in the beginning processes of getting the surgery approved for myself.  I'm excited about the possibility of having the surgery and getting healthy again. Up until my recent move to Nashville, I was in the Benefits Administration business for over 20 years.  I wanted to give some insight to everyone concerning what can be covered or not covered under a plan.  You can take it for what is worth.  You can also email me or reply and I'll try to help as best as I can. There are many different types of benefit administrators and types of insurance.  Most large companies and quite a few smaller companies (100 or more employees) are self-insured.  They hire either large companies such as Humana, Aetna, BCBS, or UHC to administer the health plan that they have created.  The money used to pay claims is supplied from premiums and the companies own insurance fund.  The insurance companies or Third Party Administrators(TPA) are paid a per employee per month fee to administer the plan.  They don't get a bonus or anything else for denying a persons coverage.  These type of plans are governed by ERISA.  There is specific guidelines that must be followed regarding approvals, denials, and appeals of benefits.  You can find ERISA guidelines in the back of your plan booklet.  You can also go to your HR Department to discuss the benefits in these type of plans. If a Self Insured Plan governed by ERISA  has specific language excluding coverage for Obesity related surgery, they aren't going to cover it regardless of medical necessity.  Many insurance consultants design the plans to excluse this type of surgery due to costs to the plan.  I don't want to get peoples hopes up that medical necessity will override a plan exclusion because I've never seen it done unless the employer specifically asks for an override to pay for the procedure.  Most self insured plans have secondary insurance policies called stoploss coverage that kicks in at a deductible level usually in the 50K to 200K range.  Once an individual person on the plan hits that mark in paid benefits the insurance coverage kicks in and the company no longer has to foot the bill on benefit payments for that particular individual.  These policies aren't going to pay for benefits that are originally excluded from the plan so companies are going to be very hesitant to approve a procedure that could end up costing their company a million dollars if there are complications. (I've seen bypass claims with complications cost this much).  ERISA plans are also not subject to many of the state regulations on insurance so double check before you appeal using a state law.  Simply ask your HR Department if the plan is self insured and subject to ERISA.  Your plan document should also have this info in it. Fully Insured plans are a different ballgame.  They are simply plans that the employer pays a set premium and doesn't really have a say in what benefits are in the plan or how they are paid.  Generally these plans are canned type plans.  They are also subject fully to state laws.  You need to know your state laws and they can be found on the state internet page in most cases. They are generally administered by the BUCA's (Blue Cross, United Healthcare, Cigna, Aetna).  You can also put Humana and other large companies in this group. (Remember they can also be just an administrator for a self insured plan so check with your employer).   In these cases it is to the advantage of the administrator to hold down costs so that the premiums collected far outweigh the benefits paid thereby created a profit center.  They should have specific guidelines about the surgery in their plan document as to whether it is covered or not and what the specific guidelines for approval are.  Even with this said,  I don't think there is rampant denial of claims to keep profits up.  Each of these companies have armies of claim analysts who interpret the benefits as best they can.  Like any other profession they have good ones and not so good analysts so don't be afraid to ask questions and keep notes of who you speak with and what was said to you for future use.  With fully insured plans you do have the ability to file complaints to the Insurance Commission.  Like anything else the more documentation that you have the better off you will be in the long run.  If a plan document is not specific in what is covered vs what is not covered courts have shown that they generally rule in favor of the patient.   I hope this information is useful for everyone.  It isn't much but I'd be happy to help anyone I can.  Like I said earlier, I'm in the beginnning processes of getting my approval through UHC.  My plan is a self insured plan that specifically covers this procedure so I'm confident that I won't have too many roadblocks.  I'll keep you posted.  I'm looking forward to participating in this site and giving and receiving encouragement and help along the way.

Thanks Vic, a very information post. I'm finding that most starting this process do not realize that there are guidelines to follow if WLS is covered or that they assume that there is coverage for this procedure and do not chec****il they are denied. Even with some of the guidelines to follow, they can be very confusing to someone never dealing with reading the language it's written.  I know the language in mine was not very clear and I was denied and now in the 2nd level of appeal.  For the most part, I could have fought mine but felt it was in my own best interest to just redo everything.  I can only gain from everything being done. While my company is self insured, there is no written exclusion but they do set guidelines.  My benefits department was very quick to tell me that they deny more than approve WLS and even if the State I live in have laws to grant WLS, I would lose the fight as they do not have to abide by any State Laws.  Discouraging but if I'm denied, I will be seeking an attorney as I have dotted every "i" and crossed every "t".   I do understand why the guidelines must be followed and it's important that others really take the time to understand them as well.  They are not designed to set us up to be denied, as they seem they are.  My only problem is that most information is overlooked and you spend countless time explaining which document this and that is.   Again, thank you for your post.