Insurance help

[phewforaminutethere 2]

Hey guys,

I've been exploring surgery as an option for several months now, doing research and such. I recently learned that my employer has WLS as an exclusion on our plans (we use United Healthcare) so I would have to pay for all of it out of pocket. :/

I have a couple of questions, though (just need some help, I'm a complete newb at insurance). We're about to have open enrollment again for the company next week, should I consider ditching insurance through my employer and paying for a different plan through a provider that does cover it?

Or should I see if there's a different/supplemental plan my employer/UHC has that does cover WLS?

Sorry if any of that is jumbled or confusing, I'm just looking for some advice to see what I should do next.

Thanks in advance!

[Chelly 364]

Call UHC and ask them if they have an additional policy that covers WLS and if they do which one of the WLS do they cover.

Now about the other insurance company call the representative and ask them what WLS they cover. They might cover one and not another so ask. Very important.

From that information that you get you make your decision of what to do.

Good luck.

[phewforaminutethere 2]

Thanks for the advice, I appreciate it!

[dsdesigna 143]

The Healthcare Marketplace has plans that cover WLS. healthcare.gov

[mcherder 13]

Pick any gold plan that covers most the surgery and co-pays. I have sliver plan but the doctor was out of network.

[catlover602 85]

I also have UHC. They would not cover wls at all! If you can afford it, shop for another insurance. Call the facility that performs wls and ask them which insurance groups cover wls, then go from there. I will be paying for the lap band myself. Good luck.

[Skinny_Krissy 12]

Hello Phewforaminutethere,

I totally sympathize - I lost four years of my life to UHC's WLS exclusions. Unforatunately you're dealing with a heartless, amoral company that doesn't think twice about ruining people's lives.

You have a couple of options: You can try to convince your employer to switch insurers or buy a rider, though UHC wouldn't even price one for my company. Put differently, it wasn't willing to sell my employer WLS coverage for ANY price, not even $1 trillion/year. Switching plans for one employee was a no-go for my HR department.

You can TRY the healthcare.gov marketplace, but since Texas chose not to require WLS benefits for its citizens, it's very unlikely that you'll be able to purchase a policy with this coverage. Typically when companies aren't required to offer this option, none of them do.

During my four years of hell, I found that I was unable to buy a policy on the "open" market for any price. Companies that cover the surgery typically won't sell to people who are fat enough to need it. So this is probably not a good option either.

Your best shot if you live near a border with another state (one that offers bariatric coverage to its citizens) is to consider moving across state lines. Otherwise, you might start looking for another job, though I changed jobs 5 times and never did get WLS coverage. Because of where you live, it's extremely unlikely that you'll be able to ditch your employer's plan and take your dollars to a company that does cover surgery, as those companies won't want to sell you a policy. Your only remaining option is to pay out of pocket, maybe in Mexico if the US is too expensive.

However, as someone who almost went to Mexico, waited until I had insurance coverage at one the best WLS surgery centers in the country, then had a life-threatening surgical complication despite having no risk factors, I can't stress enough how careful you need to be. I required weeks of tube feeding, several EGDs and a six-hour revision surgery that cost ~$136,000 before insurance discounts ($76k afterward). My good friend needed 8 corrective surgeries and was on daily TPN (IV nutrition) for 11 months. As a result, my feeling is that you need to think through the non-trivial possibility that you could have to file for bankruptcy if you self-pay and have a serious complication.

Good luck and sorry there isn't happier news.

[ChristyAZ 87]

I myself ditched my policy from work and bought an individual policy through BCBS. Its a gold plan and covered the surgery. My advise .... if your company offers multiple options, check each one over to see if WLS is a covered benefit. If not, call an insurance broker. That's what I did. I was never asked about my weight or any preexisting conditions (not sure but I think due to Obamacare, they are no longer allowed), just if I was a smoker and my age (smokers pay more). I advised I was looking for a policy that covered WLS and that's all the plans they sent me. I chose the best one for me. This was in December 2013. My new policy went into effect in Jan 2014 and I am scheduled for RNY in August. Its been a stressful 6 months but it can be done. One thing you absolutely should do is start a supervised weight loss plan NOW. Don't wait until you find a policy and then find out you need 6 months of supervised weight loss (WW was not good enough for my insurance. It had to be Dr supervised) before you can be approved. Most if not all insurance companies require it. I know my doctors/program has one through the hospital they are affiliated with. Don't throw in the towel just yet .... you're worth spending the time researching and finding a way to get the surgery. Good luck!

[Jersrose43 837]

Hey guys, I've been exploring surgery as an option for several months now, doing research and such. I recently learned that my employer has WLS as an exclusion on our plans (we use United Healthcare) so I would have to pay for all of it out of pocket. :/ I have a couple of questions, though (just need some help, I'm a complete newb at insurance). We're about to have open enrollment again for the company next week, should I consider ditching insurance through my employer and paying for a different plan through a provider that does cover it? Or should I see if there's a different/supplemental plan my employer/UHC has that does cover WLS? Sorry if any of that is jumbled or confusing, I'm just looking for some advice to see what I should do next. Thanks in advance!

Hi I have worked in insurance for 20 years. Couple things :

1- never drop employer coverage unless they pay you to do so. Free money on the table

2- you can keep employer and buy your own through obamacare

3- before you go obamacare check out what other options employer offers and be really clear on what coverage youre looking for.

To be very clear - this has nothing to do with uhc- they sell self funded plans where employers pick and choose what they can cover. If your employer has excluded the wls from this plan it's likely excluded from all policies they offer

But check first.

4- if you buy your own make sure they have the coverage. It's a federal plan and has minimum required standards. You should be able to find something.

They will both be primary coverage for you so you can pick which one you would use and the other can help pick up your deductibles, copays etc

5- the best possible option- are you married? Find out if you can get on his plan of it's covered

Use that

6- 2nd best option - are you under age 26? Get on your parents policy if possible and see if it's covered there.

Good luck pm me if you need help

[Jersrose43 837]

Hello Phewforaminutethere, I totally sympathize - I lost four years of my life to UHC's WLS exclusions. Unforatunately you're dealing with a heartless, amoral company that doesn't think twice about ruining people's lives.

This is one of the beauties if Obama care no more pre-existing questions and no changes in premium due to conditions which is great

However UHS sells policies to self funded employers and municipality's and governments based on customizable options. It really isn't them. There are many many UHS policies which do cover wls

I hope everything for you is now back on track. ????????

[2muchfun 8,927]

Jersrose is right. Your employer chose the plan without bariatric benefits because it was most likely less money. No need to dump on UHS. But there are many states that do not offer WLS even under Obamacare. Alex posted a topic on this last year btw.

[PRINCESSM 210]

As an employer I was told our plan in Virginia excludes wls and to add it to the policy makes it unaffordable. Would drive up the cost tomus and our employees and its already pretty darn expensive this year. Increased 26%!!!!

The insurance companies are charging too much for this plan!! Ridiculous considering how much healthier we can get.

[Skinny_Krissy 12]

2muchfun,

Jesrose MAY be right IF the employer is self-insured. Why would we assume this is the case? UHC does sell self-insured products to large groups and municipalities, but it also sells fully insured insurance policies (typically, though not always, to smaller groups - my 1,400-employee group uses a fully insured plan). I've had the misfortune of working for a series of companies who were fully insured, and in these cases it is not the employer who customizes the plan benefits - UHC does. So I will dump on UHC because it's an awful, heartless, amoral company and I've stood in phewforaminutethere's shoes when it comes to discovering you're covered by one of UHC's WLS exclusions.

At least in my market, UHC sells its fully insured plans on an as-is basis and won't even price riders for WLS coverage for employers who want to offer the benefits. If that's not bad behavior then I don't know what is - especially considering that UHC ended up paying way more for my obesity-caused comorbidities over four years than it would have for the original weight-loss procedure.

More to the point, it covered all sorts of "elective" procedures for non-fat employees (vascetomies for several male coworkers, an $800 wig plus matching eyebrows for a girl in the mail room with hair loss and even an eyelid lift for one woman who apparently convinced them this wasn't a cosmetic procedure) while excluding my medically necessary treatment. I'm not begrudging those people their healthcare, but we should be able to access care, too - isn't this part of the point of working, so you can get treatment when you need it? UHC has been a market leader in restricting access to WLS and it makes it impossible for even the most sympathetic employers to offer this life-changing procedure to its employees.

Anyway, I wanted to add two more longshot options that the OP should explore. The first is called an "ex gratia" provision. It basically allows your employer to pretend WLS is a covered benefit and pay for your surgery. You may also be able to access the insurer discounts UHC wrings out of hospitals and physician groups. My last company explored doing this for me, but I didn't feel I could move forward because it wasn't clear that either the company or the insurer would be contractually obligated to cover complications that followed from the surgery. On the contrary, it looked to me like they would still be excluded, though even UHC's lawyers couldn't seem to parse the language for me as they'd never encountered a situation where this was used (I am also a lawyer). I was willing to pay out of pocket for the procedure, but I wanted an iron-clad guarantee that complications would not bankrupt me. I'm glad in retrospect that I insisted on this.

The other longshot if you're not married but you have same-sex friends who work for employers that do choose to offer medically necessary treatment to their employees is to ask one of them if they'll become your domestic partner. Many large employers offer health insurance to domestic partners in states where same-sex marriage isn't legal and I actually convinced my best friend to register me as her domestic partner (neither of us is gay, but being gay isn't a prerequisite and she saw how painful it was to lose my entire 20's to obesity). However, she was laid off two weeks before the coverage would have become effective. That sucked.

Last thing: If you're under 26 and can join a parent's insurance policy, keep in mind that you will lose WLS coverage (including coverage for complications) on your 26th birthday, not December 31 of that year. Some groups now kick you off as of Jan 1 of the year you turn 26, but that conflicts with my understanding of the Affordable Care Act. This was my problem, as my mother did have coverage when I was 25 and searching for insurance options but by the time I finished the 6 month diet I would have only had 3 weeks of coverage left. Even if I could have gotten the surgery approved, scheduled and performed in those 3 weeks (unlikely), I'd still be on my own for the $150k (and counting) in complications that I experienced. Make sure you know when your coverage will terminate if you go this route, and get it in writing from the company.

[phewforaminutethere 2]

Jersrose is right. Your employer chose the plan without bariatric benefits because it was most likely less money. No need to dump on UHS. But there are many states that do not offer WLS even under Obamacare. Alex posted a topic on this last year btw.

Agreed,it is not UHS, it's definitely my employer and the selections they made going with UHS. One of the local bariatric centers does free insurance checks and got back to me on that and said it seems to be an employer driven exclusion. I plan on asking our HR rep later today if there is an additional plan I can get that covers WLS or something else I could do. After that I am looking into just paying it myself. The center I'm looking at (Kim Bariatric Institute) has an affordable program where lap band or sleeve can cost as low as $4900. I would most likely qualify based on my income.

I'm worth it and I'm not giving up on this.

I'm 26 and my mom doesn't have insurance for me to join if I were younger. I'm rowing this boat on my own and that's okay. I'm still going to get there. I'm going to remain positive about it all.

I really appreciate all of your answers, sorry I couldn't reply individually but I did read every word and it all helps. Thanks!

Edited June 30, 2014 by phewforaminutethere

[BSU 61]

I have UHC and my surgery was covered. It must vary by plan.