Texas won't approve these surgeries?

[300PoundsDown 101]

I was told by my insurance (Aetna) that there was an employer exclusion . I emailed my employer to ask why. He got more info and forwarded me the response he was given. Here it is..

This is the answer from our insurance broker about your inquiry.

You may pass on my answer to your employee. On fully insured plans in texas none of the carriers cover lap band or gastric bypass. This change happened about 5-6 years ago. It is not an option you could have elected. It simply is not covered. You can refer to your actual policy to find the exclusion. Some years past this benefit became widely abused and as your employee pointed out- it is very expensive. So the carriers stopped covering it. All the carriers. It is unfortunate because some people really would benefit from it. It is considered elective and in many cases-if the person does not change their habits-short term or even worse life threatening. So please assure your people that this was not a decision trinity made or even could have made.

Does this sound right to you guys?? Doesn't this seem to say that IN TEXAS there are NO carriers that cover lap band or gastric bypass?? As if some state law was passed across TX that no carriers are allowed to carry it. Something sounds wrong. Please give me feedback. Thanks!!!!

[pumpkin07 32]

Interesting....b/c my husband works for a Texas company and we have United Healthcare and ALL weightloss surguries & complications are excluded. But someone close to me also has United Healthcare and she can get the sleeve, bypass, or lap band covered but their employer is not based out of Texas, I think it is California.

I don't know. I was mad but didn't know what to do so I just paid for it. Frustrating b/c we pay a ton for insurance. And scarey, because what if I have complications?

[300PoundsDown 101]

I called the health insurance broker myself and she was quite helpful. Told me that Aetna told me it was employer exclusion b/c they probably that that was the case. Apparently Texas mandates some kind of across the board denial for the first time (and this seems to be more for small employers than large companies she said) She said that I should appeal it and keep at it and see what happens. Apparently my employer has no interest in trying to exclude me from it and neither did the health insurance broker .It's some Texas hoop I need to jump through. So here I go. JUMP!!

[thintopia 0]

Hi. I have Blue Cross Blue Shield of Texas and my plan does cover these surgeries. I am still in the approval process, but I have been in contact with my insurance company and have recieved documentation on thier requirements. It IS covered for sure. No one has mentioned to me that there is an "automatic across the board denial" mandated by Texas.

I look forward to seeing more responses to this post!

[yathink25 0]

thintopia did you get bcbs tx to cover the sleave if so how ?

[nsalex75 0]

I was told that BCBS TX covers the band and RNY, but not the sleeve....that is why I plan on going self pay

Nicole (newbie from TX)

[thintopia 0]

Hi all. I have not been officially approved yet because I am still in the "meeting the requirements" process.

I have received two letters from BCBS TX stating that all WLS are covered including VSG. My surgeon's office has also contacted BCBS TX on my behalf and have received the same information. That's why I am continuing on with the process for meeting the requirements.

My surgeon's office has told me that in 2010 they have already had a few VSGs approved by BCBS TX.

It may be that the BCBS TX coverage depends on your employer's exact plan. My employer is a school district with TRS Active Care . BCBS TX did tell me that not all employers have opted for the WLS coverage on their plans. According to my BCBS TX rep, it is inaccurate to say "this ins. company does or does not cover WLS". The coverage depends on what the employer has elected in the plans they offer to their employees.

Hope this helps. I will post again when I find out about my approval, or denial, whichever the case may be.

I have 11 days till I will have met EVERY single requirement BCBS TX listed on their LENGTHY requirements list!

[WingRider 1]

What a load of crap they are trying to sell you. I live and work in Texas. In the past 18 months I have been employed by two different companies. Both used Aetna. The first had all bariatiric procedures excluded because it raised the premiums to high for the employer and employees. The second employers also provides Aetna, and yes my premium went up 10.00 a month but lap band and RNY are covered. Aetna, at the time of my surgery, did not cover the sleeve period.

Your employer has opted out of providing a better insurance plan, that is the true answer. There isn't much you can do about it either, they have the right to provide what they want to provide.

Bill

[thinoneday 445]

Yup WingRider is right, I work and live in San Antonio, have United Health Care, and unless your employer has decided to be generous and include ALL bariatric surgeries to be included on the insurance, sure you'll be covered, but the majority don't do this and it's not covered. . .especially the sleeve since it's so new and there are no long term outcomes available yet. . .I was self pay too. . . but you never know. . .keep trying and good luck! keep us posted. . .