Self Funded Employer

Has anyone had any luck getting approved through a company that is self funded? I currently work for a local public school system in Florida and we are a self funded organization. Recently the board has changed our insurance to something called Pathways, which is more or less a behavior modification system in my opinion (still self funded.) There are three levels of insurance employees can get based on how compliant they are about following a strict regiment of testing. It is supposed to be a more preventative type of health insurance as everyone who wants decent coverage must get certain tests at certain ages. If an employee does not want to get a colonoscopy every five years, for example,  then they will not get the decent coverage they need. They will be dropped to a bare bones policy. I understand the logic of this type of plan but I just don't believe this is necessarily going to work. Bariatric surgery is not covered and to me this voids the whole prevention concept behind this type of insurance plan. My question is this: has anyone ever managed to get approved for bariatric surgery while working for an organization that was self funded and/or offered the same kind of tiered insurance plan? I had to undergo some lab work just to get the second level of insurance so I have documented proof already of certain conditions and my doctor can provide even more proof. There is definitely a medical need in my case and proof to back it up but in Florida, I don't believe there is any law that will force my employer to pay for the surgery even though there is a medical necessity. If anyone has had any experience or can offer any advice, I am listening. Thank you.

 
I don't believe there is a law in any state that says an employer has to provide WLS.  Perhaps one, I forget which one it is, Georgia?  Maybe?  But not Florida.

The ins is offered, you can accept or self pay for another policy but even if you did self pay for another policy, private policies do not cover WLS.

Have you tried appealing?  It couldn't hurt.  But legally, nope.  Nobody has to even provide you with ins let alone specific coverages.

There are six states that have to approve bariatric surgery if medically necessary. Unfortunately I don't live in one of them.  Now that my insurance has changed to include preventive measures, I will try again. It seems hypocritical to claim to want to prevent common (expensive to treat) illnesses and then refuse to cover a surgery that will basically eliminate my pre diabetes and drastically reduce if not eliminate my chance of getting a host of other illnesses like heart disease and cancer.  What I have going for me now is that we have partnered up with an outside medical company to administer and monitor our testing and provide 'coaching' to employees. I believe a weight loss program is covered and since I have proof of already doing a medically supervised weight loss program, I can prove I have already tried that. I am hopeful that since this company is separate from my employer, they will have a more far sighted and rational opinion of this and may support me. Or not. I have no idea until I try and I have already started the process by emailing the coach to see if she can direct me. When I first had to go for the initial blood work required by this new policy, I asked the nurses how I could get approved and they mentioned something about proving medical necessity. I can do that. However I know I can't rely on what they said as confirmation of coverage. Fingers crossed...

 
The plan admins are hired by the school you work for.  Their job is to keep costs down, they work for your employer and not you.  That's why it is so hard to get approved on these types of plans.

The plan administrator has not changed but the district now has an agreement with a medical organization to handle the medical part of the plan. I really don't know if this improves my chances or not; the district did this to reduce claims in the long term by catching and treating medical problems early. Bariatric surgery would seem to be a great example of this but I won't know until I try. I am sure I will be turned down the first time but I will go through the appeals process now that a medical entity is involved in our insurance.

My company's plan is self-funded and uses UHC as their administrator. We also have 3 levels of coverage available and they did cover my WLS.  Call your plan administrator, ask them and get a copy of the policy. Even self-funded plans are required to provide a policy. 

Walmart's ins. is self funded. They will cover NO form of weight loss surgery or weight loss anything! You'd think they couldn't afford it!!

Thanks for your reply! It is wonderful to hear that a self funded organization provided coverage. That really gives me hope. The plan administrator is First Services Administrators but the medical organization managing the medical requirements is Community Health Partners. I contacted them regarding getting coverage for this procedure. Since there is such an emphasis on prevention with this new plan I was hoping that I could get approval since I can prove medical necessity. Also, with Community Health Partners in charge of the medical aspect of the plan I am hoping they would be more appreciative of the long term benefits (cost savings) of providing this surgery to someone who is already developing very costly ailments that will result in expensive claims for many years to come. Thanks again for posting. You have really given me hope!