Question:
Has any self employed person in Maryland been approved for surgery through Kaiser or

Mamsi or Optimum Choice. It is open enrollment season again and I want to switch to either of the two. Thanks.    — liverpool508 (posted on December 3, 2003)


December 3, 2003
I've belonged to both insurances. I too live in Maryland. I have to tell you that I ended up switching to Kaiser becuase MAMSI was the worst. Kaiser will cover you, BUT, you have to meet the NIH criteria and there are several other steps you have to take. Let me tell you about MAMSI first. I was told that they would only cover me after 6 months of strict supervised dieting. But, covering meant that they would only pay for the surgery. Not anesthesia, not medications, not follow up appointments....just the surgery. So, I switched to Kaiser. Kaiser wasn't up front about their requirements but I'll tell you. You have to attend a Nutrition for Weight Loss class, get a psychiatric eval. with a Kaiser paychiatrist, and meet with a Kaiser nutritionist for 6 months. Now, the nutritionist worked with me to learn about post-op eating and planning. It wasn't to prove that I was dedicated. I hear now that they want you to lose weight now...it is a requirement. I think 10% of your excess weight, I could be wrong. They said something about attempting to lose weight unsuccessfully in the past. That wasn't a biggie. The psychiatrist asks you about that and your doctor would probably know about that anyway. Regardless, they can't deny you if you meet the requirements. I wish you the best luck. Don't go to MAMSI...they were the worst when it came to this surgery. I know that Kaiser takes a little while but it's worth it in the end. I had mine on August 22 after fighting with both insurances for over a year and a half. I was fighting with Kaiser because I didn't know what I had to do...once I found out their requirements it was pretty easy. BE PERSISTENT!!! Oh and also, Kaiser only permits to surgeons to do the surgery...Dr. Lin and Dr. Anez. I went with Dr. Anez and haven't looked back. If you have any other questions please email me.
   — Morna B.

December 3, 2003
Oh my!!! Ok, I guess I should have paid more attention to your question...I didn't realize that you were self-employed. I'm sorry, well, if you still have any questions then please email me.
   — Morna B.

December 3, 2003
I don't know about Mamsi, but I have Kaiser like Morna (Hi, Morna - how YOU doin'??). Even though you are self-employed, I would think the policy for Kaiser will be the same and you'd have the same requirements. The reason I think the policy will be the same is because my employer offers 2 insurance policies and they have a written exclusion on the other policy, but not on Kaiser. So I think Kaiser has one policy and you get the whole package with no exclusions. Morna covered the Kaiser requirements very well and if meet their requirements and follow what they say, you'll get approved. One caveat to what Morna said -- until now Kaiser has only approved open RNY procedures. However, they are now looking closely at lap RNY and according to my nutritionist, they will probably add at least one more doctor to the referral list - one who does lap RNY (neither Dr. Anez or Dr. Lin do the procedure lap). So if you decide to go with Kaiser, by the time you're ready for approval, I am certain they will have added the option of having the procedure done lap. Good luck!
   — antiques55

December 3, 2003
You should be able to contact Kaiser directly and asked if there are any exclusions on the self-employed policy for gastric bypass surgery. Usually members services dept can help. OR there may be a # listed on your open enrollment forms to ask questions. I'm not self employed, but do have Kaiser. When we checked with members services I was told that as long as my primary care doctor considered it medically necessary, it would be covered. My cost has been $15 per office visit, no cost for special testing requried, and $100 if I would of had the surgery this year (I had to cancell at the last minute, but hope to reschedule soon). Co-pays differ according to you policy. Next year our co-pays go up to $20 per office visit and $250 for the hospital say. So that is my total cost. Each region is different on what they require for authorization for surgery. My profile explains what I have gone thru but I'm in California. We really like Kaiser and feel we get exceptional care from them. However here in our area, they do not do the surgery so am going to UCLA for that.
   — [Deactivated Member]

December 3, 2003
Make sure when you call the insurance company you ask is it excluded from the policy. I know for a fact Mamsi MDIPA/OCI do cover it under some policys. To qualify you must have 6 most sup visit, Nutrtionlist, Physc eval. I think we talked almost a year ago about carfirst self employment open enrollment and we both got denied. It sucks but I finally got a job at MAMSI and it is covered and I am having the surgery DEC 16 th. Yeah... Please make sure you ask for a written list of exclusions from both insurance companies before making a decision. Good Luck. Maricha
   — MyWlsProgress

December 3, 2003
Since you are self employed have you thought about BC/BS? They have a pretty good individual plan and I know that they approve without making you jump through too many hoops. Remember that it has been written into law in Maryland that if proven medically necessary, the surgery must be covered. Regardless of what the exclusions say. Good luck!
   — Pambylah

December 3, 2003
I don't have Kaiser but several close friends do. Kaiser had a ton of hoops before surgery would be approved. You have to go for visits to their psych's, prove weight loss attempts, have co-morbids etc. For one friend it took 12 months, another 18 mos to get approved. The big problem for both of them was the 6 required visits to a psych.
   — M B.

December 4, 2003
I wish to thank you all for the advice. I have requested packages from both. I will let you know the outcome.
   — liverpool508

December 19, 2003
Just to clarify, Kaiser doesn't normally require 6 months worth of visits to a psych, but they do require 6 months worth of visits with a nutritionist. Kaiser DOES want to know that you're serious and willing to do what is necessary to be successful post-op. Yes, they have strict guidelines, but they will treat you fairly.
   — antiques55




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