Molina Healthcare Ohio (Medicaid) Insurance qualifications !

Ok, so today I recieved the packlet of papers from Premier Bariatrics in Dayton, Ohio with the Molina Healthcare bariatric surgery qualifications.
I will list their qualifications for surgery below.

1. 6 month physician supervised diet to include: Monthy weigth-in for consecutive months (No skipping Months). Type of diet must be notated. Exercise plan or increased activity plan. Behavior modification all completed by Primary care physician.

2. Primary care clearance form and a letter of medical necessity form your family physician stating your co-morbid conditions, diets that you have attempted, height, weight, and body mass index. This letter MUST be on your physician's letterhead. Also done by your physician.

3. Psychological evaluation: based on surgical weight loss procedure and psych. readiness.

4. 5 year weight history documented in physician progress notes. You must have the past 5 years. Also done by physician.

5. Cardiac and Pulmonary evaluation and clearance for surgery. Referals may be done by your physician.

6. Bloodwork specifically for: hypothyroidism ande H-Pylori. Done by your primary physician.

7. Drug testing: Drug and alcohol screen this labwork is done by you primary physician.

8. Nutritional evaluation: This will be arranged for you at your first visit with the surgeon ande is based on the type of procedure you have. This is set up at premier bariatrics after you have a consulation with the surgeon.


** NOTE**
In this paperwork, it did not mention how many co-morbid conditions are required per the BMI scale. I'm assuming that they do not require a specific number, though, I could be wrong.

 That all sounds right except I didn't have to have five years of medical history and weight.  Just two...

But it's all very simple to get this all done.   I have completed everything in 3 weeks besides the cardio physical and that's scheduled for next Tuesday.  :)   Oh, and the psych eval but we are doing that during my next appointment with the surgeon since they are in the same office.   

How is everything going with this? My husband lost his job shortly after thanksgiving and we will hear of all the assistance we will  get sometime next week. We should qualify for Medicaid. I have been wanting and waiting for WLS for the last 4 years. If we qualify for Medicaid, I am going to immediately get started on the process. I would just like to know how everything is going with your approval. I would hate to go through all of this only to be denied.

Good so far. I am currently on my fifth month of the supervised diet/training required. Once I am done early March we are submitting to insurance for approval. If you have a BMI over 40 you will qualify easily with Molina. You just have to do the 6 month diet. And do the drug/alcohol test, cardiac clearance, pulmonary clearance, and sleep study. I had all the testing done the first month.

After you get the Medicaid do not pick Caresource as your managed care plan. They require a 9 month diet!!! Molina is the best I think. Definitely start the process now. You will more than likely have to do an informational session from the surgeons office before they will schedule the first appt. And most only hold those once a month and then it can take awhile go get first appt. Start now because it is a long process with Molina.

Hi Misty!

Thanks for sharing your journey thus far, I've noticed that it was a few months ago and I wanted to ask how it has ended up? What procedure did you end up going with and where did you have tbe surgery done?

I too have Molina Healthcare & am with Ohio Health. I still have to get three years of weight history put together and all of the other tests will fall in line. They are not making me do a sleep study because I do not have breathing problems, I do not smoke, nor do I snore or have sleep apnea. All of the testing will be done through their network and it just happens to be a 45 minute drive one way. It would really break my heart to be denied at the end of my 6months with all the hoops that I will end up jumping through. I have a BMI of 54 and take two medications daily for hypertension. I was also denied referral to see a surgeon by a neurologist because of my weight but I was not seen by a surgeon and retain a note from him to support the cause. I had a severe back injury in 2010, bulging, tearing, completely herniating 4 disks. I also have plantar fasciitis with multiplte bones spurs. They do not consider these two conditions to be grounds for coverage, but to relieve some of this pain is a miraculous dream.

I was so glad I don't have Caresource!  I have Paramount Advantage with Medicaid and only need six months supervised diet and two years weight.  But my bmi is over 60 so it helped to get approved.

I'm wondering if this varies by doctor?  I also have Paramount and only had to have 3 months monitoring with the dietitian and no weight history (though I went in with it, they didn't need it.)  I was approved within a week of submitting for approval. So, I started my process in January and am having surgery June 8th!  :)  My BMI is over 40.

can I ask where your psych evaluation was completed?? I'm having a hard time finding anyone who'll take molina in the miami valley area

 

Mine was done at my bariatric center.  

 Hi misty! I am currently trying to get the ball rolling for wls. I live In ohio and also on Molina. I've been reading mixed things about coverage. I called molina and spoke with them about coverage and they said ya they will cover it if I met the requirements. Which surgeon did you use? Did you get any denials prior? What did you complete prior to prior auth being submitted? I did jenny craig 6 months ago, would that count as my 6 month diet? Who does the diet need to be supervised by? Sorry for all the questions, I just seen you were done pretty quick and seem to know the ropes :)

-Shayna