Insurance ?

[BeatrizS1974<3 sleeve 94]

Hi, Im new here and have a quesiton for you all.

Back in late Feb/ early March when i started this journey i had Amerihealth. Insurance was willing to cover the sleeve 100% after my $300 Deductable. I had to do 6 visits with the Nutritionist before approval.

On March 26 i found out that the company my husband works for was changing insurance carriers effective April 1.

We went from having Amerihealth to now having Meritain Health/ Aetna.

Just called the new insurance company because i want to know what my coverage is and wanted to clarify if i still had to do 6 months with the nutritionist or if the nutritionist is right and its now 4 months.

They don't have an answer for me. The employeer has not sent in the explaination of benefits yet and when i asked the agent on the phone he told me it could take a month or two.

Its driving me sick not knowing if i will be or wont be covered and if its going to be 6 months or 4 months.

Has anyone else gone through this?

[ProudGrammy 8,322]

Its driving me sick not knowing if i will be or wont be covered and if its going to be 6 months or 4 months. Has anyone else gone through this?

I also had problems with my insurance company. My primary was Medicare, who denies the sleeve. My seconday, from work was blue cross blue shield, who usually accepts the sleeve. but wasn't sure.

I kept calling blue cross, and calling, and calling......i finally got the positive answer i was looking for, didn't hear til i pestered them so much that they eventually worked with me and i got the answer i was hoping for.

Don't give up, you keep calling too til you get some help back and then a good final word.

Best of luck

kathy

[BeatrizS1974<3 sleeve 94]

Thanks Kathy for your reply. I will call them every week if i have to. lol

[atkinsoncl 62]

Oh no, I hope you get the answer you are looking for. Unfortunately, I can't help you much, but I do know that it is up to your employer to add weight loss surgery to your benefit plan. I can't see why it would take up to two months if you have the benefits now. I agree, keep calling. Good luck!! Hope you find out soon!

[gorjess907 16]

I have Meritain Health (a company of Aetna) and am currently in the 4th month of weight loss management. With my plan, they require me to have a medical rehablition consultant for case management. I was just assigned to a consultant (she is sooo nice) and she has been helping with my case. Unfortunatly i was only able to get in a few quetions before she left this week for vacay, but she has been a big help with answers! I know that Meritain will cover VSG, but my case manager is going by Medicare Standards to review for necessity. Medicare does view the VSG as investigational, but she said we may be able to use other criteria for this form of surgery.

My requirements our as follows

*Must be at least 18 years old

*BMI of 40 or higher that has persisted for at least 3 years or

*BMI of 35 and less then 40 with (a list) comorbidities...

*Must have continued to be obese despite partcipation in a supervised weight management program for at least 6 consecutive months. The program should incorporate nutritional counseling, behavioral modification, and approprieat reqular physical activity

*Participate in multi disciplinary preoperative evaluations as identified by a physician and or nurse case manager.

I am 24 years old (check)

BMI 46.7 (check)

I am on my 4th month of WLM and im still obese (obviously with my bmi so high! ) (check)

I have had a gym membership for a few years now, and i go a couple times a week, and nightly walks (how am i to prove that?)

now for the behavior modification,nutritional counseling.... dont know how to check this off this list yet...

perop evals? dont know how to meet this yet either

I live in Alaska, and have chosen Dr. Hunter with Virginia Mason in Washington state. So far I have been in contact with his nurse Steve, and he has been a MAJOR help with my flood of questions. I have a consultation/ nutritionist/pyschologist meetings lined up in July I hope these will check a few off my list of requirments LOL

As far as prices - Dr Hunters nurse Steve says about $16000.00 out of pocket but her refferd me to VM billing and they gave me an estimate of about $35000.00- $45000.00 billed to insurrance, I believe my plan with meritain covers 80%-90% and I think there is a $20000.00 break point. Now if i could find my out of pocket/after insurrace amount that would be helpful!

Hope this helped a little, I have a hard time finding info/answers in these forums for Meritain

Good Luck with your journey!!!

[BeatrizS1974<3 sleeve 94]

Thanks for all the info! Well we will soon find out if i will be covered. I am so nervous that after all the work that i have put into getting this surgery they wont cover me. So i am praying hard!

The Nutrituional counseling and behavior modification can be crossed off your list by visiting a nutritionist. Meritain required me to do 4 visits with the nutritionist.

they also required 5 years weight history (which i was able to get from my pcp)

6 months of failed weight loss programs (which luckily i had done 4 months of Jenny Craig and 2 months of weight watchers

My navigator has recieved all that stuff and so now once i go to my Pre-op nutritional class (on wednesday) and my Consent signing appointment (thursday) they will fax everything to the insurance co.

Keeping fingers crossed!

[ebonisekim 1,713]

This is what I'm going thru except my new plan doesn't active until aug. 2012 and my health insurance now is breech street which covers it I'm afraid that this new one won't Aetna ... I'm tryna continue and prepare for the new insurance tryna go by thier requirements ...sad thing is that I don't no if my employer excluded it and would they consider it a pre existing condition ?