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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