Issues with Highmark in PA

[Blithe5678 0]

I ran into an issue today with my Highmark Flex Blue PPO 1000 insurance. The first rep I spoke to in Feb, said that I would have to cover 20% of the sleeve surgery, but today the rep said I wasn't covered at all for anything and there were no notes about the previous rep I spoke to.

Because of my income I can get on Medicaid in Pennsylvania. I have been paying for insurance out of pocket, because I like my family doctor and I didn't want to have to go to a clinic. However, the surgeon's office said that it will be covered 80% and there maybe other things like the hospital that won't be covered.

Has anyone in PA used medicaid for a sleeve?

Did anyone in PA have a Highmark policy that covered surgery?

I'm not sure if I should go for Medicaid or upgrade my policy to something that covers bariatric.

Any other suggestions/help?

Thank you!

[Jersrose43 837]

So I looked it up and they're correct not covered for the plan- excluded.

Look at bariatric.

If you do qualify for Medicaid in pa See second link for state by state coverage rules

https://www.highmarkblueshield.com/sbc/pdf/sbc/I_1888891696_20140101_SBC.pdf

http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/downloads/medicaid-mc-enrollment-report.pdf

[Blithe5678 0]

Thank you for the links jersrose! I was going to pull out my hard copy of the plan when I got home to double check. I was under the initial impression that the way the surgery was coded would override exclusions listed as such.

I will look into the Medicaid link you shared as well.

I just wish it would be easier to see all of highmark bsbc plans to know if any of them would cover it. But their website is very counterintuitive. Which I assume is on purpose.

[Jersrose43 837]

The way it is coded will be completely irrelevant to the medical policy. Coding is a very serious business and Mis coding is considered insurance fraud. They won't put something on there you don't have. The code for a sleeve is a code for a sleeve and will be rejected.

In some cases things can look at the diagnoses and change the coverage but not for something like this. That would be for items like cosmetic surgery. Medical vs behavioral and such.