asked HR to add coverage to policy... no go!

[Candle 11]

What state are you guys in?

I can offer some advice for people in NY.

I was successful purchasing a self pay plan that covered the band for me. (my policy with Anthem BC/BS also had an exclusion, due to our "small business" status)

[Ozzy&OdiesMommy 0]

I'm in KY. I think I can purchase a plan as well. I just need to figure out the best way to go about it. I have wonderful insurance through my husband's job, except the lap band proceedure is excluded. Can I get secondary insurance to cover me, or would I have to cancel with my husband's insurance.

Thanks!

[Marimaru 7]

Unfortunately an exclusion is an exclusion. I'm 95% sure that if it's excluded, you're just out of luck, no matter WHAT the insurance company would avoid paying for by paying for your band.

I agree with Alexandra though, the day is coming where this wont be so hard to get paid.

[Kat77 0]

I am from Western NY and would like to hear more about the additional policy you purchased.

[Candle 11]

I purchased a plan with GHI. It's called Alliance Value and is about $415.00 per month. My company picked this up for me since it's almost what they were paying for my BC/BS plan.

GHI covered the surgery 100%. They required a 6 month supervised diet with my PCP first though.

The catch and downer about this policy is that it doesn't cover office visits. All visits related to the pre-op tests can get expensive! What I did was keep my BC/BS until all my pre-op tests and the 6 month diet were done and then switched to GHI.

I can't guarantee this will work for everyone but it worked for me.

You can get info from GHI directly or on ehealthinsurance.com about their plans.

[amanda2008 0]

thanks Candle, I looked up plans on ehealthinsurance.com.

It looks like I can get my own plan at UHC that does not exclude the surgery!

I am going to apply... I wonder if they will approve me, knowing that I am switching from a group plan to an individualized plan?

[Candle 11]

Every state has different laws about insurance.

That doesn't seem like a reason they could exclude you. There are many reasons for someone to change insurance plans.

Make sure you do your homework before you switch!! Make sure, with out a doubt, they cover the surgery. It seems like most self pay plans exclude WLS. Check on co-pays and deductibles, check on surgery guidelines, (I had to do the 6 month diet) and find out about pre-existing condition clauses.

Good luck!

[amanda2008 0]

This is their only mention of weight loss surgery in the exclusion section of this policy:

"No benefits are payable for expenses which:... Are incurred for cosmetic or aesthetic reasons, such as weight modification or surgical treatment of obesity."

Which seems like a normal exclusion saying they won't pay for anything just for cosmetic reasons.

I'm wondering about pre-existing conditions - would this even apply for WLS? isn't one of the requirements be years of being overweight?

[Candle 11]

Obesity is a pre-existing condition.

Again - it depends on your state's laws. In NY, as long as you've had continuous insurance coverage for 18 months and there isn't a gap between insurance plans of more than 61 days, the new company can't deny anything "pre-existing". I had to prove to my new company I had coverage previously or they would have made me wait out the pre-existing condition period of 11 months - then cover surgery.

There are a few threads pinned at the top of the forum - one with CPT codes. I would call the insurance co with that code and ask specially about the band and their requirements. Even if they do cover WLS, that doesn't mean they cover it 100%. What if you have to pay 50% on top of paying for this new plan?

Search everything you can on that company on forums like this one and OH.com to see what other people's experience was with them.

Be sure to let us know how it works out for you!!!