Employer self-funded insurance
Hi everyone,
My employer has a self-funded insurance policy. Blue Cross Blue Shield of NC manages the policy, though, and, as far as I can tell, what we have is BCBS's Options plan.. even though we're self funded.
Here's my question - has anyone had any luck asking for a review when you're turned down for surgery with a self-funded policy? I honestly don't know how these self-funded things work. I know that I'd have to send the request to BCBS, but if they deny yet again, can you go to your employer?
They cover most WLS, (and have been approving gastric bypasses like gangbusters lately) though for the DS, which is what I'd like, you need a BMI of >50; for the rest of the surgery types you need a BMI of >40, which is what I have, so I know that I will be turned down. Another thing I'm wondering might help me: I work for Social Services, and it's my understanding that we will cover the DS for people with a BMI of >40 through Medicaid (I have not been able to find anything online to confirm this, however). If this is true, do you think I can use the fact that we cover our clients but not our employees in my favor? Argh insurance.
My employer has a self-funded insurance policy. Blue Cross Blue Shield of NC manages the policy, though, and, as far as I can tell, what we have is BCBS's Options plan.. even though we're self funded.
Here's my question - has anyone had any luck asking for a review when you're turned down for surgery with a self-funded policy? I honestly don't know how these self-funded things work. I know that I'd have to send the request to BCBS, but if they deny yet again, can you go to your employer?
They cover most WLS, (and have been approving gastric bypasses like gangbusters lately) though for the DS, which is what I'd like, you need a BMI of >50; for the rest of the surgery types you need a BMI of >40, which is what I have, so I know that I will be turned down. Another thing I'm wondering might help me: I work for Social Services, and it's my understanding that we will cover the DS for people with a BMI of >40 through Medicaid (I have not been able to find anything online to confirm this, however). If this is true, do you think I can use the fact that we cover our clients but not our employees in my favor? Argh insurance.
Hey Kite
Here is the NC Medicaid medical policy. From what I read (mind you I just skimmed) it looks like the requirement is still >50 for DS but read thoroughly. You might find something to help you fight your cause.
http://www.ncdhhs.gov/dma/physician/1a15.pdf
Here is the NC Medicaid medical policy. From what I read (mind you I just skimmed) it looks like the requirement is still >50 for DS but read thoroughly. You might find something to help you fight your cause.
http://www.ncdhhs.gov/dma/physician/1a15.pdf
"There is a skinny woman trapped inside of me. I can usually shut her up with cookies and chips but today I am setting her free"
Hello-
I've worked in this industry for several years now and have found that most medicaid plans have the same criteria - they are dictated by medicare who also have the criteria of BMI>50. I think your best bet is to work with your employer group. While they may not be able to influence the insurance company's criteria, they may be willing to look at other options for employees like you wishing to have weight loss surgery. My company has been successful helping self-funded employer groups look at providing weight loss surgery to their employees in a cash-pay model. We offer complication protection and soon we will offer financing as well. The employer groups that we have already worked with are receptive to this idea because it actually saves them money. To learn more about our company, visit www.bliscompany.com or click on the link to the left side of this forum. Also, please feel free to contact me as well. Best of luck to you! Billie
I've worked in this industry for several years now and have found that most medicaid plans have the same criteria - they are dictated by medicare who also have the criteria of BMI>50. I think your best bet is to work with your employer group. While they may not be able to influence the insurance company's criteria, they may be willing to look at other options for employees like you wishing to have weight loss surgery. My company has been successful helping self-funded employer groups look at providing weight loss surgery to their employees in a cash-pay model. We offer complication protection and soon we will offer financing as well. The employer groups that we have already worked with are receptive to this idea because it actually saves them money. To learn more about our company, visit www.bliscompany.com or click on the link to the left side of this forum. Also, please feel free to contact me as well. Best of luck to you! Billie
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