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morgans
on 12/18/10 9:23 pm
VSG on 06/18/12
Topic: RE: Bummer - no obesity coverage AT ALL
I would prefer the sleeve.

       
WASaBubbleButt
on 12/18/10 11:57 am - Mexico
Topic: RE: Bummer - no obesity coverage AT ALL
 
BTW, might want to check out my blog and see HOW to research a MX or US surgeon.  I don' have one for bypass or DS yet.

wasabubblebutt.blogspot.com/2010/03/researching-mexican-or-us-sleeve.html


Previously Midwesterngirl

The band got me to goal, the sleeve will keep me there.

See  my blog for newbies: 
http://wasabubblebutt.blogspot.com/
WASaBubbleButt
on 12/18/10 11:47 am - Mexico
Topic: RE: Bummer - no obesity coverage AT ALL
On December 17, 2010 at 4:57 AM Pacific Time, morgans wrote:
After a few back and forth phone calls and several re-reads of my insurance exclusion policy it is confirmed - they do not cover any type of obesity treatment at all. Crazy, I know. I know it's just the plan that I'm on - not necessarily the insurance company. I have the same company (Humana) that approved a breast reduction 2 years ago, and if they'd approve that they'd approve this.

Again- it is my particular plan level, not the main insurance co - an important distinction to remember. I have the option of upgrading but I"m going to wait and see what the new year brings in terms of promotion at work, husband's potential new job, etc. I only just started thinking about this so I'm not very far down the track at all.

Financing certainly is an option - my car is paid off in July and that monthly bit of budget could easily go towards this.

If you've financed - how did you do it? Regular credit cards, personal loan, cosmetic credit?

 
I went to Mexico and wrote a check... twice.  Ugh.  But well worth the results.  I started out with a band and revised to a sleeve.

What surgery type are you considering?


Previously Midwesterngirl

The band got me to goal, the sleeve will keep me there.

See  my blog for newbies: 
http://wasabubblebutt.blogspot.com/
morgans
on 12/16/10 8:57 pm
VSG on 06/18/12
Topic: Bummer - no obesity coverage AT ALL
After a few back and forth phone calls and several re-reads of my insurance exclusion policy it is confirmed - they do not cover any type of obesity treatment at all. Crazy, I know. I know it's just the plan that I'm on - not necessarily the insurance company. I have the same company (Humana) that approved a breast reduction 2 years ago, and if they'd approve that they'd approve this.

Again- it is my particular plan level, not the main insurance co - an important distinction to remember. I have the option of upgrading but I"m going to wait and see what the new year brings in terms of promotion at work, husband's potential new job, etc. I only just started thinking about this so I'm not very far down the track at all.

Financing certainly is an option - my car is paid off in July and that monthly bit of budget could easily go towards this.

If you've financed - how did you do it? Regular credit cards, personal loan, cosmetic credit?

       
(deactivated member)
on 12/16/10 8:06 am
Topic: RE: Approval question
I think it will be at the same rate, since the surgeon and hospital are both contracted to Aetna. I hope... I will make some more calls and find out..
WASaBubbleButt
on 12/16/10 7:44 am - Mexico
Topic: RE: Approval question
On December 16, 2010 at 3:07 PM Pacific Time, Staceeann wrote:
Yes, I was approved out of network because the medical group we are assigned to is very small and there is no surgeon who does the DS. Dr. Crookes and the hospital are both contracted with Aetna, just not my medical group.
 
This one I'm sure is probably fine but I'd still check with someone who knows a whole lot more than me.  It worries me that they specifically state they will not cover out of network yet in this case they have no choice.

I'm not sure how to CYA on this one.

Do you have anything in writing showing specifics of what you will have to pay the out of network providers?  Will it be at the same rate?


Previously Midwesterngirl

The band got me to goal, the sleeve will keep me there.

See  my blog for newbies: 
http://wasabubblebutt.blogspot.com/
(deactivated member)
on 12/16/10 7:07 am
Topic: RE: Approval question
Yes, I was approved out of network because the medical group we are assigned to is very small and there is no surgeon who does the DS. Dr. Crookes and the hospital are both contracted with Aetna, just not my medical group.
WASaBubbleButt
on 12/16/10 6:50 am - Mexico
Topic: RE: Approval question
 
Did they approve you out of network?  Is there some reason such as they have no in network providers that do your surgery type?

I would get in writing that they will pay out of network since your policy clearly states they will not.



Previously Midwesterngirl

The band got me to goal, the sleeve will keep me there.

See  my blog for newbies: 
http://wasabubblebutt.blogspot.com/
(deactivated member)
on 12/16/10 6:41 am
Topic: RE: Approval question
Hi, My husband emailed Aetna and this is what they  sent him back:

Thank you for using your secure member website to contact Aetna.  To
help protect your confidential information, please continue to use our
online form to contact us.  The online form provides greater security
than standard Internet e-mail.

Your benefits
Your plan includes coverage for in-network services only.
* You must select a primary care physician (PCP) to access to your
benefits.
* Your plan has a $30.00 copayment per visit with your PCP.
* You must have a referral from your PCP to see a participating
specialist.
* Your plan has a $30.00 specialist copayment per visit.
* Your plan has a $150.00 copayment for an outpatient surgical procedure
when done at a participating outpatient surgical facility.
* Your plan has a $300.00 copayment for an outpatient surgical procedure
when done at a participating hospital.
* Your plan has a $500.00 copayment per day with a maximum of a
$1,500.00 copayment per admission for inpatient hospitalization.


According to our precertification file I was able to find your wife has
been authorized for two days. If additional days are needed the hospital
should call us get any additional days authorized at that time. If they
are authorized those additional days would be covered. There is no
maximum on the number of days that someone can be in the hospital, these
authorizations are based on medical necessity. The maximum comes in on
the copay amounts for inpatient hospital stays not the number of days a
patient can be in the hospital.  Basically your plan has a copay of
$500.00 per day while in the hospital with a maximum of $1,500.00 per
admission.  This means that whether you are in the hospital for 3 days
or 30 days the most you have to pay out of pocket for that stay is
$1,500.00.

* If you use an out-of-network provider for your care, then you will be
responsible for the full cost of the services. (does this count if they approved me out of network?)

Your plan has a yearly out-of-pocket maximum of $3,000.00 per person, up
to the family out-of-pocket maximum of $6,000.00 each calendar year.

Your plan has an unlimited lifetime maximum per person.

The information provided above is not a guarantee of coverage. Coverage
is based on all the terms and conditions of your plan as well as
eligibility at the time services are received.

If you have questions, you can reach Member Services by logging on to
www.aetna.com or www.aetnanavigator.com and selecting the "Contact Us"
feature.  You may also call the toll-free number on your member ID card,
if applicable.

So I think I am clear on everything but the Red Part. If you know the answer to that could you let me know? Thanks, I just wanna make sure I have no surprises> Staceeann
B. Bap
on 12/16/10 4:23 am
Topic: RE: Changes to FEP BCBS for 2011
The sleeve was covered previously, but I think it had additional requirements, such as  BMI of 45 and co-morbidity.
But for the 2011 year, I believe that additional requirement is removed.  I have not confirmed this with the insurance company but I read it on another forum.

Good luck all.
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