Aetna, BCBS or United Healthcare???

[AmandaD. 35]

Hello!

Semi-new here, just starting my journey and trying to get everything situated as much as possible. I am starting my journey in January after I choose/enroll in my job's insurance in October. I know the basic coverages for each insurance plan they offer, and (thankfully) they all offer bariatric coverage. I am having a hard time deciding on which to go with as I know they all have their own specific criteria. I am not having the best of luck getting further information on specifics from neither my workplace or the insurance companies on any specifics and they are both blaming the other party (my job stating the insurance company will have more info/insurance companies stating they need to know the exact policy from my job to give all the info)... I'm ready to pull my hair out as this seems like a huge decision to make going in blindly.

I was just wondering if anyone has had any of these insurance companies and your general experience -- I know it depends on specific policies but just in terms of ease/customer service/questions answers/timeliness/billing with these insurance companies? I'll take any advice now to help with my decision!

Thank you ☺️

[SleeveToBypass2023 2,637]

I have BCBS of Illinois and they covered everything but $1500, and my secondary covered $1200 of that. So I only had $300 out of pocket. They approved my surgery within 48 hours of my surgeon's office submitting everything. From my 1st appt to my surgery date was 2 1/2 months. BCBS only required 1 pre op and 1 post op nutritionist appt, 1 psych eval, approval letter from my neurologist (because I have MS), approval letter from my PCP, having tried at least 2 methods of weight loss in the past (my PCP knew about me doing Keto and also low/no calorie and put that in the approval letter). So it was a fast and painless process. My surgeon's office wanted the blood work and EKG before surgery. BCBS approved every test with no issues.

[AmandaD. 35]

On 08/16/2022 at 16:16, SleeveDiva2022 said:

I have BCBS of Illinois and they covered everything but $1500, and my secondary covered $1200 of that. So I only had $300 out of pocket. They approved my surgery within 48 hours of my surgeon's office submitting everything. From my 1st appt to my surgery date was 2 1/2 months. BCBS only required 1 pre op and 1 post op nutritionist appt, 1 psych eval, approval letter from my neurologist (because I have MS), approval letter from my PCP, having tried at least 2 methods of weight loss in the past (my PCP knew about me doing Keto and also low/no calorie and put that in the approval letter). So it was a fast and painless process. My surgeon's office wanted the blood work and EKG before surgery. BCBS approved every test with no issues.

Oh wow! That’s great. To be honest I used to have BCBS when I was pregnant and they royally messed up my claims so I am very hesitant of getting them again but I do wish for a smooth process! How did you know what their criteria was? Was it through your job that you had to figure that out or did you call BCBS and just let them know your plan name?? I’m trying to get a criteria and no one can give me specifics - they said they have to wait until I select the policy… but I have three insurance company options, I want to know BEFORE I choose, you know? Thank you for the information. This whole process is crazy haha

[SleeveToBypass2023 2,637]

57 minutes ago, AmandaD. said:

Oh wow! That’s great. To be honest I used to have BCBS when I was pregnant and they royally messed up my claims so I am very hesitant of getting them again but I do wish for a smooth process! How did you know what their criteria was? Was it through your job that you had to figure that out or did you call BCBS and just let them know your plan name?? I’m trying to get a criteria and no one can give me specifics - they said they have to wait until I select the policy… but I have three insurance company options, I want to know BEFORE I choose, you know? Thank you for the information. This whole process is crazy haha

So I called them, and it took 3 different calls, but they were able to tell me a little (they confirmed I have the coverage, and because I have the diamond plan, it has the absolute most coverage). SO then when I had my first appt with my bariatric surgeon, I was able to speak with the person who handles the insurance and she pulled up my coverage and was really able to give me more clarity on what's covered (basically, all 3 major bariatric surgeries, all the testing, the psych eval, and the 2 nutritionist appts). It really depends on the level of coverage you choose. The higher the plan, the more coverage you get. I have MS and I have had every medication, every MRI, every specialist, every EVERYTHING covered no questions asked. Same with my bariatric surgery, same with PCP, same with pretty much everything. Lower plans (and this goes for any insurance) cover less. Higher plans cover more.

Edited August 16, 2022 by SleeveDiva2022

[AmandaD. 35]

[AmandaD. 35]

On 08/16/2022 at 17:25, SleeveDiva2022 said:

So I called them, and it took 3 different calls, but they were able to tell me a little (they confirmed I have the coverage, and because I have the diamond plan, it has the absolute most coverage). SO then when I had my first appt with my bariatric surgeon, I was able to speak with the person who handles the insurance and she pulled up my coverage and was really able to give me more clarity on what's covered (basically, all 3 major bariatric surgeries, all the testing, the psych eval, and the 2 nutritionist appts). It really depends on the level of coverage you choose. The higher the plan, the more coverage you get. I have MS and I have had every medication, every MRI, every specialist, every EVERYTHING covered no questions asked. Same with my bariatric surgery, same with PCP, same with pretty much everything. Lower plans (and this goes for any insurance) cover less. Higher plans cover more.

Ok, thank you for that information! Did you get your surgery done in a hospital setting or specialist with his own Bariatric practice? Seems like I just need to pick a insurance and hope for the best haha

[KimA-GA 540]

My health insurance plan does not cover bariatrics (united health) but my husband put me on his plan which started covering bariatrics this year (anthem/bcbs state health benefit plan -Georgia school employee insurance)

I have had to get:

a sleep study

3 months consecutive weight loss program/advisement by dr

Psychological exam (virtual)

cardiac exam/clearance

nutritionist consult (virtual)

endoscopy

weekly inhealth coach visits (virtual)

1 year history from primary dr

letter of recommendation from primary dr

I am mostly done with the requirements.. so far I am lacking one consecutive dr visit (aug 29th), doing cardiac testing tomorrow and endoscopy sept 6th. Don’t have surgery date yet, but end of September or first week in October likely.

remember, bariatric coverage is not insurer specific but plan specific. Your plan has to have coverage and no exclusion. Most plans have exclusions in my experience. More are covering it, but they are usually very large employer plans with good overall coverage (expensive coverage )

it’s getting closer and real!

Edited August 16, 2022 by KimA-GA

[AmandaD. 35]

On 08/16/2022 at 18:48, KimA-GA said:

My health insurance plan does not cover bariatrics (united health) but my husband put me on his plan which started covering bariatrics this year (anthem/bcbs state health benefit plan -Georgia school employee insurance)

I have had to get:

a sleep study

3 months consecutive weight loss program/advisement by dr

Psychological exam (virtual)

cardiac exam/clearance

nutritionist consult (virtual)

endoscopy

weekly inhealth coach visits (virtual)

1 year history from primary dr

letter of recommendation from primary dr

I am mostly done with the requirements.. so far I am lacking one consecutive dr visit (aug 29th), doing cardiac testing tomorrow and endoscopy sept 6th. Don’t have surgery date yet, but end of September or first week in October likely.

remember, bariatric coverage is not insurer specific but plan specific. Your plan has to have coverage and no exclusion. Most plans have exclusions in my experience. More are covering it, but they are usually very large employer plans with good overall coverage (expensive coverage )



it’s getting closer and real!

Thank you so much for that information! How do you figure out plan exclusions? I work for a large bank and in their little healthcare “breakdown” it shows Bariatric surgery is covered (in-network with “distinguished centers”) covering 80% after co pay/out of pocket max. With that I am assuming that because the “brochure” states it’s covered that means that all three options my job provides for medical insurance will cover it. My job only lists very minimum criteria (must have BMI over 35, dietician, Psych, etc.) nothing specific, no exclusions listed. I would love to figure all of this stuff out BEFORE I pick an insurance company/plan, but when I call my jobs HR they tell me I have to contact the specific insurance company and tell them the plan & when I call the insurance companies they state the need a “group number” from my job and cannot give me any information until they have it. I can’t even look for specialists/surgeons because no one will even tell me who’s in network. It all just seems crazy to me that no one can tell me ANYTHING.. I feel lost and stumped as to where to look next… do I wait for open enrollment and HOPE that there may be an HR rep that can give me more info or do I have to blindly pick an insurance to go with and hope that their criteria/exclusions aren’t too crazy? Or would it be the same criteria/exclusions across the board because that’s what my job puts into place? I probably sound crazy but I just don’t seem to understand the whole process. It seems like my job, the insurance company AND my specialist/surgeon will all have their own criteria to go by… I just wish I could get all that information (or atleast some of it) before hand… thank you for listening and anymore insight would be much appreciated! Congrats with almost being done with your pre op journey!! That must be so exciting!!!! Are you getting the sleeve or bypass? I’ll be doing the bypass because I have GERD. I’m terrified of the endoscopy ( I hateeee needles) the best of luck on your continued journey!!!

[KimA-GA 540]

Ask to speak to your insurance broker … they can answer that about the available plans

[KimA-GA 540]

Oh and I am getting a sleeve.. I know too many people with issues with bypass that sent them to the hospital over and over again It isn’t for me! (But everyone should do what’s good for them)

my surgeon fixed hiatal hernia with sleeve which brings the gerd rate down to about 10% of patients .. I am a bit freaked about the endoscopy (and surgery!) but know it’s the right thing

[SleeveToBypass2023 2,637]

20 hours ago, AmandaD. said:

Ok, thank you for that information! Did you get your surgery done in a hospital setting or specialist with his own Bariatric practice? Seems like I just need to pick a insurance and hope for the best haha

My surgeon is one of 4 doctors that jointly own their practice. And he has privileges at one of the better hospitals here and my surgery was done there. I chose the sleeve because I have pills that can't be broken and that have no alternatives (my MS meds) and you can't take pills with the bypass. Also, the complication rate for sleeve is way lower than with bypass. Lastly, the types of BCBS you can get also differ. The ones provided to state employees seems to require more testing than BCBS through a regular employer. At least, that's what I've noticed.

[merrymayhem 7]

On 8/16/2022 at 2:16 PM, SleeveDiva2022 said:

I have BCBS of Illinois and they covered everything but $1500, and my secondary covered $1200 of that. So I only had $300 out of pocket. They approved my surgery within 48 hours of my surgeon's office submitting everything. From my 1st appt to my surgery date was 2 1/2 months. BCBS only required 1 pre op and 1 post op nutritionist appt, 1 psych eval, approval letter from my neurologist (because I have MS), approval letter from my PCP, having tried at least 2 methods of weight loss in the past (my PCP knew about me doing Keto and also low/no calorie and put that in the approval letter). So it was a fast and painless process. My surgeon's office wanted the blood work and EKG before surgery. BCBS approved every test with no issues.

I also have BCBSIL, seeing Dr. Weaver, and have MS! I'm getting the RNY though, I take Kesimpta (monthly injection). I think I'm going to have to pay my deductible ($200) plus out of pocket max ($2500) but I'm not sure yet, I should probably call them. Hoping they count my prescription copays (covered by a manufacturer copay card) towards out of pocket max like my last insurance did, I should get at least one fill before surgery ($250 each).

[SleeveToBypass2023 2,637]

9 hours ago, merrymayhem said:

I also have BCBSIL, seeing Dr. Weaver, and have MS! I'm getting the RNY though, I take Kesimpta (monthly injection). I think I'm going to have to pay my deductible ($200) plus out of pocket max ($2500) but I'm not sure yet, I should probably call them. Hoping they count my prescription copays (covered by a manufacturer copay card) towards out of pocket max like my last insurance did, I should get at least one fill before surgery ($250 each).

Everything counted towards my out of pocket. I was able to meet it in no time. You'll love Dr Weaver. He's really, really good!!!

[destructapie 1]

On 08/16/2022 at 17:48, KimA-GA said:

My health insurance plan does not cover bariatrics (united health) but my husband put me on his plan which started covering bariatrics this year (anthem/bcbs state health benefit plan -Georgia school employee insurance)

I have had to get:

a sleep study

3 months consecutive weight loss program/advisement by dr

Psychological exam (virtual)

cardiac exam/clearance

nutritionist consult (virtual)

endoscopy

weekly inhealth coach visits (virtual)

1 year history from primary dr

letter of recommendation from primary dr

I am mostly done with the requirements.. so far I am lacking one consecutive dr visit (aug 29th), doing cardiac testing tomorrow and endoscopy sept 6th. Don’t have surgery date yet, but end of September or first week in October likely.

remember, bariatric coverage is not insurer specific but plan specific. Your plan has to have coverage and no exclusion. Most plans have exclusions in my experience. More are covering it, but they are usually very large employer plans with good overall coverage (expensive coverage )



it’s getting closer and real!

How did you get it approved since your primary didn’t cover it?

[KimA-GA 540]

16 minutes ago, destructapie said:

How did you get it approved since your primary didn’t cover it?

because it’s covered in my second plan

the first plan denied it and second plan pays for what the first does not made a lot of my costs all the preliminary appointments go way down. (cardiac testing went from 800 out of pocket down to 75, sleep study worked out to be free, nutritionist and psych free)

because of the two plans my surgery and hospital stay was just $850 out of pocket