Confused- Medicaid Vs. Managed Care Req?

[boogie_badd8nt_she 43]

Maybe someone here can help me understand why the company who's managing my care(Molina) has different approval requirements than what medicaid is asking to qualify?

Medicaid (According to Law),is saying 35 with Co Morbid and Molina says all I need is BMI of 40 (which I have). Anyone understand this??? I've talked to them but no explains it in a way I understand.

Is it Molina who's making the decision..is it medicaid? Lol

Anyone approved through Apple Health Molina with No comorbidities? Or any insight would be great. I'm confused as h***!

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[Bufflehead 6,358]

I had a somewhat similar situation with my insurance provider having one set of requirements and the plan administrator having completely different requirements. I wasn't sure whose rules would apply! The person who helped me straighten it out was the insurance coordinator at my surgeon's office. If you have a surgeon picked out, make an appointment to speak with their coordinator and if they are reasonably knowledgeable and skilled, they will either know the answer or be able to figure it out right away. It is their job!

[KristenLe 5,979]

Your policy with Molina should be the deciding factor. It is usually 35-39 with comorbities or 40+ with OR without. My guess is you're just not getting the right answer from Medicaid.

[boogie_badd8nt_she 43]

I had a somewhat similar situation with my insurance provider having one set of requirements and the plan administrator having completely different requirements. I wasn't sure whose rules would apply! The person who helped me straighten it out was the insurance coordinator at my surgeon's office. If you have a surgeon picked out, make an appointment to speak with their coordinator and if they are reasonably knowledgeable and skilled, they will either know the answer or be able to figure it out right away. It is their job!

It's really confusing when I'm told that the requirements are straight forward and i should be fine And then you witness people getting denied and constantly shaking in their boots.. thanks ladybug!

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[boogie_badd8nt_she 43]

Your policy with Molina should be the deciding factor. It is usually 35-39 with comorbities or 40+ with OR without. My guess is you're just not getting the right answer from Medicaid.

There's a letter sent from the hospital that's I'm planning on going to stating the requirements by state law. And it says 35 with top 4 Co Morbid or rare comorbid. But when I call Molina they say there are three ways to get approved. BMI 40,BMI 35 with comorbidities,or 30-34 with DM II or metabolic syndrome. The only way to understand i guess is to just allow the process and cut out the guess work.. I hate doing stuff for nothing. Ya know?

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[KristenLe 5,979]

I hear you! I never was able to get my requirements from BCBS. I'm just going by what my surgeon's office said. The Molina data appears correct from what I could see online.

[boogie_badd8nt_she 43]

I hear you! I never was able to get my requirements from BCBS. I'm just going by what my surgeon's office said. The Molina data appears correct from what I could see online.

I'm surprised they told me!!! Because everyone usually just says "Go to your PCP, they can offer you the information" ... yeah I know but what if my PCP sucks! Haha

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[Chicken Lady 102]

I have Molina-Apple health.

There are different obesity categories for insurance. Molina will approve it if your BMI is over 40.

It's a different set of requirements if your BMI is below 40. That's when you need to have at least one comorbidity.

You should have a caseworker available to you that can help you through the process. I had a caseworker and it actually made the process very easy. She had all of my information ready with the insurance company so that when the surgeon submitted it she was waiting for it and it got approved in just a few days.

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[boogie_badd8nt_she 43]

chicken Lady" data-cite="Chicken Lady" data-ipsquote-timestamp="1466752449">

I have Molina-Apple health.

There are different obesity categories for insurance. Molina will approve it if your BMI is over 40.

It's a different set of requirements if your BMI is below 40. That's when you need to have at least one comorbidity.

You should have a caseworker available to you that can help you through the process. I had a caseworker and it actually made the process very easy. She had all of my information ready with the insurance company so that when the surgeon submitted it she was waiting for it and it got approved in just a few days.

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Ohhh okay!! So my case worker is the person currently assigned to me...?, or do you get a different case worker specifically for weight management cases or approval? Apologies,..I'm just beginning the process. Thank you for your input. I appreciate it!

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[boogie_badd8nt_she 43]

chicken Lady" data-cite="Chicken Lady" data-ipsquote-timestamp="1466752449">

I have Molina-Apple health.

There are different obesity categories for insurance. Molina will approve it if your BMI is over 40.

It's a different set of requirements if your BMI is below 40. That's when you need to have at least one comorbidity.

You should have a caseworker available to you that can help you through the process. I had a caseworker and it actually made the process very easy. She had all of my information ready with the insurance company so that when the surgeon submitted it she was waiting for it and it got approved in just a few days.

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Or did mean a case worker at the surgeons office?

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[Chicken Lady 102]

No, I had a specific case worker from my insurance co. Her job was to guide me through the process and be my contact person at Molina. If I had questions about the process (financially or insurance) she was my contact. , she called me now and then to check in on me and see how I was doing or if I needed anything.

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[Chicken Lady 102]

What state are you in?

I'm at the "approved but waiting for surgery " stage so if you have any questions about working through the process - let me know .

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[boogie_badd8nt_she 43]

What state are you in?

I'm at the "approved but waiting for surgery " stage so if you have any questions about working through the process - let me know .

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I appreciate it. I had been thinking about getting the sleeve for years, but unfortunately I lived in Arkansas and I didnt meet requirements.

I'm actually in Tacoma area. I have Molina-Apple Health and trying to get a feel of what it does and doesn't cover. I did the 6 mos. Diet, Psych eval, TSH..you name it. (back in AR ) found out a simple BMI of 40 wasn't enough no comorbidities. I was devastated because it was time consuming and lack of navigation from the surgeons office.

I'm awaiting my appt. currently to pitch the idea to my new PCP here in WA. I will obviously have to go through the UW-CENTER of Excellence ????.

What did you need to be approved? Any other health conditions? They require years of proof of obesity?( 5 years )

I appreciate you reaching out..there aren't many with our insurance on here that I can find. So thanks.. !!!!

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[Chicken Lady 102]

I am going to University of Washington Weight LossManagement Center in Seattle. (One of 2 places in WA our insurance will cover- the other is in Spokane)

They did not require me to show 5 years obesity (but not hard to find proof of that) and I didn't have any real co morbidities.

I had my dr write the referral. Then Molina will approve or deny you for stage 1.

If approved - there are 6 months of dr visits.

- monthly weigh in at PCP

- 12 visits to NUT

12 visits to PT

12 visits to psych. ( not nearly as scary as it sounds.)

* the hardest requirement was that I had to lose 5% of my starting weight- which I met through the PT.

I was able to start UW before my final visits were over. I started back in September, went to UW in February. Started their testing in March.

UW required a swallow & ph study, upper GI, EGD, and blood work.

I had a case worker that was my contact person and she was waiting for my paperwork when I was done.

I was approved for surgery in just a few days

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[Chicken Lady 102]

Just got my date! July 27

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