help understanding my surgery Premera B/C Heritage Plus 1 program
Hi I recently started working for a company here in Wenatchee WA, Columbia Valley Community Health. It has pretty good insurance Im told. I did see that there is a written exclusion for weight loss surgery, but also checked this site and see that similar people who have the same insurance as we do, were approved for surgery. I cant really afford to pay for this surgery out of pocket, and my husband makes too much money for me to get medical assistance I believe. My co-morbid conditions are getting worse, and I know I need to have this surgery. My doctor has written three letters for me, and all denied. Can anyone tell me how with this type of insurance they got approved for the surgery?
Thanks,
Kathy in Wenatchee.
Hi there,
I too am covered by an insurance that often pays for WLS and additionally have insurance through my husband who's insurance also has paid for WLS. My insurance coverage for me however, which is decided by the companies we both work for, exclude any type of WL surgery or any type of WL assistance. So, my understanding is that the company you work for decides what they will have covered or not with the insurance company they choose for their company.
Not good news but hope that explains a bit. I am paying privately for my RNY, we are dipping into the little bit of retirement we have. Scarey.
I have heard of some people going to their company (job) and asking for a "rider" which they put into place to cover the surgery for the employee. I don't know much more about that. I am not going to do that but I know some have and have had success in getting their WLS covered.
Good luck with whatever you do!
Cheryl
We never touch people so lightly we do not leave a trace.
Peggy Tabor Millin
It completely depends on the policy of the company and what they have chosen to have coverage for. I have Premera blue cross which often has WLS as an exclusion, but the company I work for is self-insured, meaning Premera administers the policy but the company pays all the costs themselves. Because of this I believe my insurance is better and covers a huuge range of things from naturopathy, to WLS being offered as a covered benefit with no waiting period, no referral, no nutrition counseling, pretty much no hoops to jump through... 100 people could have Premera Blue Cross Heritage Plus 1 like me but have totally different benefits.
If they have a written exclusion then your best bet is to go to a consult, and have the surgeon write a letter to your insurance company asking for approval. If they deny, appeal. Rinse and repeat.. You can hire legal counsel too.. not really sure much about going down that path, but I know it can be done.
Good luck!
Another option is if one of your employers offers different health plans, to switch during open enrollment. My company offers 3 different health plans- 1 through Group Health, and 2 through Premera. The other Premera plan has the exclusion written in big black letters as well. And group health basically would only offer coverage if hell froze over, or so I've heard.
I chose the plan that didn't have it written in - it is basically a PPO where you have higher copays and out of pocket expenses (the copays are $20 vs. $5 for example) but it has out of network coverage and you can go to any doctor without a referral, etc. The plan also does not have Obesity surgery outlined in the benefits when you look online or in the booklet. I found out by calling them that they offer coverage for obesity surgery.
If you have other health insurance options, it would be worth while calling them to find out if they offer the benefit and then switching during open enrollment. If this isn't an option, then hopefully the letter of medical necessity written by the surgeon will do the trick. Asking your company to help with the insurance aspect is also not a bad way to go, but I can totally understand not wanting to do that. I am not telling anyone in my company that I'm having this surgery, because I think people would freak out at the fact that the company is paying for it, since there are still so many misconceptions about obesity surgery being easy and unnecessary.
Anyway, good luck!
I chose the plan that didn't have it written in - it is basically a PPO where you have higher copays and out of pocket expenses (the copays are $20 vs. $5 for example) but it has out of network coverage and you can go to any doctor without a referral, etc. The plan also does not have Obesity surgery outlined in the benefits when you look online or in the booklet. I found out by calling them that they offer coverage for obesity surgery.
If you have other health insurance options, it would be worth while calling them to find out if they offer the benefit and then switching during open enrollment. If this isn't an option, then hopefully the letter of medical necessity written by the surgeon will do the trick. Asking your company to help with the insurance aspect is also not a bad way to go, but I can totally understand not wanting to do that. I am not telling anyone in my company that I'm having this surgery, because I think people would freak out at the fact that the company is paying for it, since there are still so many misconceptions about obesity surgery being easy and unnecessary.
Anyway, good luck!
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