Question:
Self-funded -- even State mandate doesn't apply

I am at the very beginning stages of learning about and deciding whether WLS is for me. I decided to call my insurance to see what their reaction was. I was told that my insurance is self-funded and even though Maryland has the recent state mandate regarding coverage for WLS for necessity, unless my employer agrees to change what they will pay for, my insurance won't cover it. I work for a large, conservative law firm and I can tell you it would be a huge up-hill and probably fruitless battle to get this changed. I don't know if I am up for that kind of battle. I have had enough disappointment in my life to go through a lot of testing and spend hours on supporting documentation just to have it shot down. I don't need that. On the other hand, I just recently learned my blood pressure and cholesterol are not good and if I can't get them regulated, I may need to take medication for them. Has anyone found approval through your employer to be anything than a huge fight? Law firms are notorious for keeping their eye on the financial bottom line and I don't think they're going to buy into this. Suggestions??? Please feel free to e-mail me. I can't check the boards too often. Thanks!    — antiques55 (posted on May 13, 2002)

May 13, 2002
Lori, The company I work for is also self funded. I have learned from Blue Cross and Blue Shield that they can opt to pay out of contract for the procedure. Your battle now is with your employer. My suggestion to you is to gather tons and tons of information. Find out who makes the decisons in your company and set up a meeting with them. Allow yourself to be vunerable and pour your heart out to this person. I also live in Maryland and would be happy to go to the meeting with you to show a success case. I am down 55 lbs in 11 weeks.
   — Diane Rhoads

July 8, 2002
I have a self-funded plan offered to state of Texas employees w/the same exclusion you posted. I've been working w/the group at COMPASS, used to be IMAGES, and they've confirmed that the BCBS-TX exclusion isn't iron-clad because the medically necessary clause has worked, and they're working with me to get approval based on that. I know there are several who've tried to get past this based on a LOMN and were denied, but my case-worker lady seems confident based on the information provided by her contact at BCBSTX. I'm not approved yet...but there's still hope based on the LOMN. See below: Dear Lynda, I spoke with Lettie at Blue Cross today and was told that they will consider this surgery if medically necessary, however as you have an HMO they will not allow you to go out of network. I noticed that you stated that you will roll over to PPO in September. I would suggest we wait until after September 1 to submit the letter of medical necessity for approval as they will certainly deny it due to being out of network. Please let me know how you would like to proceed and thanks for letting us know that they will consider this procedure. Up to now we have always been told that this was a "definite exclusion" on this policy even with medical necessity. Thanks and I look forward to hearing from you. Sheridan at Compass GOOD LUCK EVERYONE!! :)
   — Lynda L.