Why some insurers won't cover WLS

[shriner37 249]

In researching VSG I came across an interesting explanation as to why some insurance plans cover weight loss surgery and others do not. I can't confirm the accuracy of this explanation but it sounds very plausible.

There are generally two kinds of insurance plans: employer funded and commercial plans.

Employer funded plans are used by many employers with more than 500 participants as it is more cost effective to fund their own plans. They will use an insurer to administer the plan, but since most of the funding comes from the employer they have a big say in what is covered (within lawful restrictions).

Commercial plans are offered by insurers to the general public, or to smaller employers. They are funded by the insurance company through premiums and investment of their assets. The health plan, not the employer is on the hook for costs in this case.

Many commercial plans do not cover WLS because they realize that their membership is very transient and change plans often. For example someone who is a member of a Blues plan this year is likely to be a UHC or Cigna member next year. Health plans understand the long term healthcare cost savings of WLS but do not want to spend their dollars today to generate savings that will help out the plans the member will participate in 5 or 10 years down the road.

Many employer plans take a longer view of this situation, realizing that as long as you are employed with them they will have responsibility for your healthcare costs, and thus are more likely to pay for WLS as a long term investment in your health.

So when a health plan denies coverage or publishes a specific exclusion, they may not be stupid, just focused on their short term financials.

[OutsideMatchInside 10,166]

It still really depends on the plan and the state. I am self employed. I purchased a plan. It covers WLS. It covers my Vitamins (which are expensive) and most insurance doesn't.

With Obamacare, if you live in a state that considers WLS an essential service (most do), you are more likely to have WLS covered by commercial insurance than employer. Employers can pick and choose what they cover. They are trying to keep costs low and are more likely to exclude.

Reading the insurance forums, almost everyone denied or forced to jump through a ton of hoops are on an employer plan. I bought my own plan and picked a plan that covered what I wanted. I wasn't forced into a plan that my employer selected.

Edited August 27, 2015 by OutsideMatchInside

[AngelaWilliamsMD 290]

It still really depends on the plan and the state. I am self employed. I purchased a plan. It covers WLS. It covers my Vitamins (which are expensive) and most insurance doesn't.

With Obamacare, if you live in a state that considers WLS an essential service (most do), you are more likely to have WLS covered by commercial insurance than employer. Employers can pick and choose what they cover. They are trying to keep costs low and are more likely to exclude.

Reading the insurance forums, almost everyone denied or forced to jump through a ton of hoops are on an employer plan. I bought my own plan and picked a plan that covered what I wanted. I wasn't forced into a plan that my employer selected.

I completely agree with the above post!

[shriner37 249]

Reading the insurance forums, almost everyone denied or forced to jump through a ton of hoops are on an employer plan. I bought my own plan and picked a plan that covered what I wanted. I wasn't forced into a plan that my employer selected.

Ironically my experience has been just the opposite. My employer (a big healthcare company) offers a number of plans. Most are self-funded but in certain markets they also offer commercial plans from big health insurers as a courtesy. Our national health plan is company funded, managed by Aetna and WLS is covered. However they also offer a plan from the local BCBS (a good customer of the company) which isn't funded by the employer. I have BCBS and WLS is specifically excluded. When I asked why I was told that the Aetna plan is company funded, while the BCBS plan is a commercial plan offered as a courtesy.

I opted to go self pay instead of waiting for the 1st of the year to switch insurances then go through the medically supervised weight loss period which would likely be required.

As I said, I was just relaying what I was told in explanation as to why one employer offered plan covered the surgery and another didn't.

[OutsideMatchInside 10,166]

The problems is because you live in Kansas.

http://nofusa.org/news/health-insurance-cover-obesity-treatment/

States that do not offer bariatric surgery, nutrition counseling, or weight loss programs in the State Health Insurance Marketplace are: Alabama, Alaska, Florida, Georgia, Indiana, Kansas, Kentucky, Minnesota, Mississippi, Missouri, Nebraska, Pennsylvania, South Carolina, and Wisconsin.

An employer plan can choose to cover WLS surgery in your state, but no other plans are required to because your state does not consider WLS an essential service. All other states that are not on this list do, and private plans will include WLS surgery, while employer plans can opt out if they choose to.

[amazon 579]

I'm not sure it's so easy to figure out why. Seems to me to be driven by the management of each company.

My company is self funded, and has been for as long as I can recall and I've been here 15 years. They've never had any coverage related to weight loss (no reimbursement for weight watchers, gym membership, etc, nor WLS). Each year the plan has covered less, and the cost has either gone up, or co-pays/deductibles increased. Two years ago they removed the HMO option and now only offer a high deductible plan, with bio-metric screenings.

My state, however, covers WLS under Mass Health.

I am fortunate that my husband's company offers an excellent plan with the coverage I needed. But I think those days are numbered.