Insurance Coverage

[sonnysun 15]

I have gained so much knowledge from this forum. My only remaining questions deal with insurance and financing.< /p>

I have BCBS of Texas.

We emailed them regarding a possible surgery for me and received a letter that said:

For a member to be considered eligible for benefit coverage of bariatric surgery to treat morbid obesity, the member must meet the following two criteria:

BMI equal or grade to 40 kg/meter OR BMI equal or greater than 35 with at last 2 comorbidities (listed below).

AND

Documentation from the requesting surgical program that

*Growth is completed

* Documentation from the surgeon attesting that the patient has been educated in and understands the post operative regimen, which should include ALL of the following components:

Nutrition program AND

Behavior modification or behavioral health interventions AND

Counseling and instruction on exercise and increased physical activity AND

Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health AND

Patient has completed an evaluation by a licensed professional counselor, psychologist or psychiatrist within the 12 months preceding the request for surgery. This evaluation should document:

The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical recommendations AND

The absence of an eating disorder AND

The patients willingness to comply with preoprative and postoperative treatment plans.

My BMI is right at 40, so I read this as saying all I need the is psych evaluation before we can schedule surgery, and then I need to comply with everything after surgery. Is that right, or do most policies read like this and I'll still be expected to comply with a waiting period before scheduling?

Also, my insurance says that:

When utilizing one of our participating providers at a in network
facility, your coverage for an eligible medical necessary approved
Bariatric surgery provided by an M.D. and the related facility charges
is 80 percent of allowance after you meet your deductible of $400.00.
The in-network individual out of pocket maximum is $2900.00. The
benefit maximum is one visit/procedure per lifetime. At this time, you
have satisfied your in-network individual deductible and the amount of
$651.34 has been applied to your individual out of pocket
maximum for the 2015 calendar year.

Does that mean if I use an in-network provider my maximum out of pocket cost will be $2900? Is that paid before the surgery?

Thank you!

[Daisee68 2,493]

So I don't have BCBS but out of pocket Max should mean same everywhere. And you are correct or well you only have $2248.66 left (2900 less 651 credited). Yes you will have to pay this most likely to either the hospital or the Dr before they will do surgery. Don't pay both of them or you will have to get money back. (That's the boat I am in now.). Typically you have a coincidence after u meet deductible and before you reach out if pocket. So for example my confidence was 20%. So after my deductible. If I had a covered Dr visit of $1000, then I would pay $200 of that and insurance would pay $800. Then that $200 gets added to your out of pocket costs so u would then only have $2048.66 left to pay. Make sense? On your first question, I am going to let someone else answer for sure but my understanding is you have to do a lot of those visits before being approved - ie how else will Dr document that you have been educated in all those areas listed?

[sonnysun 15]

Thank you so much!

I think it reads that all the education and stuff is post operative? I found it strange which is why I asked!

[sonnysun 15]

And, I guess my big question is, if I meet the requirements listed in their policy, can I still be denied if I'm deemed not medically necessary? Or does meeting the requirements mean I will be accepted? Thanks for all your help!

[laguerr13 993]

Legally an insurance company may be held liable if a surgery was necessary due to a medical condition, so most companies don't want to deal with the implications that are associated with it, just make sure your surgeon's office complies with all the requirements necessary also, you lay have to try a couple of times, mine fell under morbid obesity, And health conditions associated it with it were an extremely high BMI, years of dieting, body pain, high blood pressure and apnea, good luck and don't just say ok if your insurance company says no, many policy holders are uneducated and don't realize that there are systems in place if they do deny you.

Edited July 21, 2015 by laguerr13