Cariten Insurance Alert
I have just learned that Cariten will NOT be covering Weight Loss Surgery in 2004 for any of their fully funded plans. If you are in open enrollment and selecting an insurance plan Cariten and Blue Cross are the least likely to cover in Tennessee.
Both these carriers do have some self funded plans that cover wls but none of their own policies the ones they call "fully funded" will cover Weight Loss Surgery.
Jama
It's such a shame that these insurance companies just can't get the clue! People, let's get a letter writing campaign going to our congressmen and women in Nashville and get a law passed to require them to pay for this life saving surgery! We can make a difference! Below is the Virginia state law, which was passed to require THEIR ins companies to pay!
§ 38.2-3418.13. Coverage for the treatment of morbid obesity. A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services shall offer and make available coverage under any such policy, contract or plan for the treatment of morbid obesity through gastric bypass surgery or such other methods as may be recognized by the National Institutes of Health as effective for the long-term reversal of morbid obesity. The provisions of this section shall apply to any such policy, contract or plan delivered, issued for delivery, or renewed in this Commonwealth on and after July 1, 2000. B. The reimbursement for the treatment of morbid obesity shall be determined according to the same formula by which charges are developed for other medical and surgical procedures. Such coverage shall have durational limits, dollar limits, deductibles, copayments and coinsurance factors that are no less favorable than for physical illness generally. Standards and criteria, including those related to diet, used by insurers to approve or restrict access to surgery for morbid obesity shall be based upon current clinical guidelines recognized by the National Institutes of Health. C. For purposes of this section, "morbid obesity" means (i) a weight that is at least 100 pounds over or twice the ideal weight for frame, age, height, and gender as specified in the 1983 Metropolitan Life Insurance tables, (ii) a body mass index (BMI) equal to or greater than 35 kilograms per meter squared with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes, or (iii) a BMI of 40 kilograms per meter squared without such comorbidity. As used herein, BMI equals weight in kilograms divided by height in meters squared. D. The provisions of this section shall not apply to short-term travel, accident-only, limited or specified disease policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or governmental plans or to short-term nonrenewable policies of not more than six months' duration. (2000, c. 465; 2003, c. 462.)
§ 38.2-3418.13. Coverage for the treatment of morbid obesity. A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services shall offer and make available coverage under any such policy, contract or plan for the treatment of morbid obesity through gastric bypass surgery or such other methods as may be recognized by the National Institutes of Health as effective for the long-term reversal of morbid obesity. The provisions of this section shall apply to any such policy, contract or plan delivered, issued for delivery, or renewed in this Commonwealth on and after July 1, 2000. B. The reimbursement for the treatment of morbid obesity shall be determined according to the same formula by which charges are developed for other medical and surgical procedures. Such coverage shall have durational limits, dollar limits, deductibles, copayments and coinsurance factors that are no less favorable than for physical illness generally. Standards and criteria, including those related to diet, used by insurers to approve or restrict access to surgery for morbid obesity shall be based upon current clinical guidelines recognized by the National Institutes of Health. C. For purposes of this section, "morbid obesity" means (i) a weight that is at least 100 pounds over or twice the ideal weight for frame, age, height, and gender as specified in the 1983 Metropolitan Life Insurance tables, (ii) a body mass index (BMI) equal to or greater than 35 kilograms per meter squared with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes, or (iii) a BMI of 40 kilograms per meter squared without such comorbidity. As used herein, BMI equals weight in kilograms divided by height in meters squared. D. The provisions of this section shall not apply to short-term travel, accident-only, limited or specified disease policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or governmental plans or to short-term nonrenewable policies of not more than six months' duration. (2000, c. 465; 2003, c. 462.) 
No, I"m not exactly sure when Virginia enacted it. I'll do some research to see if I can find out. FOr the PHP Tenncare question, PHP has no choice but to pay for it as it is a covered procedure under Tenncare guidelines. If you meet Tenncare's guidelines, then they are required to pay for it, whether their parent company excludes it or not.
Sherri,
Any legislative info we can come across may be helpful. We all need to be contacting our Tennessee Representatives. Doug Overby has taken an interest in our cause and IS willing to help. Please everyone contact your state legislatures and let them know that you feel WLS coverage by insurance should be mandated by law.
Jama
I have sent letters to both my state representative and senator. To find out who yours is, here is the link to the TEnnessee General Assembly. Click on the House link and the SEnate link, then on members to find out who you should write. http://www.legislature.state.tn.us/
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