Sharon1964

You might want to check and see if you are even eligible to still have your father's plan. GENERALLY, if you can be claimed as a dependent by someone else (your husband), you cannot be claimed as your parent's dependent, which means you cannot be carried on your parent's policy. A lot has changed in the last several years, and what I said may no longer be true. But definitely, check to see if a married child who is no longer her parent's dependent can still be carried on their health insurance.

Yes, that's what it means. One of the things you didn't list was the amount of your maximum out of pocket per year. If a plan has a $5,000 max out of pocket, for example, then you will never pay more than that for the year in expenses (not including premiums). So while you have to pay 1000 for your deductible then 10% after that, if that 10% is more than $4000 (using our example), you won't have to pay anything more than $4000. Also, make sure all of the plans will cover the procedure that you want to have done.

Sigh. Look how optimistic I was there! My insurance doesn't count the first visit with the surgeon as part of the six-month nutrition program. So my last appointment won't be until June. Which means my surgery will likely be July. I was hoping for June for many reasons, one being that the company I work for is moving in July, and I wanted to have it done and take the time off before the move. Blah.

Some people who have never been there just can't understand. "There" can be many things, including: weight problems substance abuse problems mental health problems Can an alcoholic stop drinking just because they know they should? Can someone who is depressed just snap out of it? I think this is one of those things that your husband just can't understand.

Thanks! Oh, and I'm not having the band, I'm having sleeve gastrectomy.

Call the doctor's office and ask them. If the doctor doesn't want children in the consultation room, you wouldn't be able to leave the kids alone in the waiting room without someone else with them.

My surgeon requires a colonoscopy prior to gastric surgery if you're over age 50. I had mine in January. While I was under, they also did an endoscopy and took a biopsy of my stomach. The colonoscopy is covered at zero copay to me, as it is one of the special screening procedures. I expected a small bill for the additional work for the endoscopy. The hospital bill came in the mail. My insurance paid around $1500, and they said my part was around $1600, which was a combination of deductible and copay. I called my insurance company and asked if the colonoscopy was indeed covered at 100%, and they said yes. So I said if I had only had the colonoscopy, my portion would be zero. How is it then, that adding a minor procedure that was performed while I was already in the operating room, already under anesthesia, caused my portion to go from zero to $1600?? The rep said he would attach the surgeon's bill to the hospital bill to show it was mostly a screening procedure, and send it back for review. I got the result today in the mail. My insurance company paid the $1600 they originally said was my portion, bringing my portion to... ZERO!

@@Alex Brecher That's not the problem, this is something new. The first time I reply to a thread, I auto-follow it. The next person who posts, and those thereafter, trigger notification. In the last two days, my FIRST post on a thread generates a notification that someone posted on a thread I'm following. This hasn't happened before.

It sounds like you took an assessment called the Minnesota Multiphasic Personality Inventory, or MMPI. It's about 400 true/false questions. You may have answered some questions showing you subconsciously had some lingering regret about your marriage, your husband, or your divorce. I know there weren't any questions specifically about marriage, but that's the way these things work.

This person is not a psychologist as that requires a doctorate. She is likely a marriage and family therapist (MFT), licensed clinical social worker (LCSW) or the equivalent in your state. Not only would I complain to your surgeon, I would file a complaint with her state licensing board. And by the way, you are being way overcharged. A Master's level therapist makes about $50 to $75 per 50 minute session in a mid-sized city. I would mention that to the surgeon as well. Sharon (before I changed careers to running a pain management office, I ran mental health offices for about 13 years)

I think you're doing everything you should be doing. Did you have any comorbidities? On appeal, I might argue that the treatment was for those diseases, not merely as a tool to lose weight. And I might use some phrases and sentences like, "I find it abhorrent that your customer service agents, for a period of XX months, and on at least XX separate occasions, assured me that this procedure was a covered benefit, when in fact it was not. You allowed me to have hope that I could finally live a normal life. You allowed me to have hope that I could fit into the world. You allowed me to have hope and then, you so callously destroyed that hope with nothing more than "oops, we made a mistake." Imagine having a fatal disease, being told for months that you could be cured, then hearing, "oops, we made a mistake". Your repeated mistakes have devastated me. I know you can make an exception, and I implore you to make an exception for me, as you misled me for so long. Please make this right."

@@Shace Dude, it's not you. It's the level of fat in your body and how that influences your testosterone levels. As men's abdomens get larger, their level of testosterone decreases. Fat cells can actually produce estrogen (from what I've read). So when a guy is heavier, he has less testosterone and more estrogen. When that reverses, he has increased testosterone, which can cause problems with anger. Not a doctor, blah blah blah. Oops, sorry, didn't realize this was in the guys room. Pretend I used my deep voice.

Independent Health has numerous plans. You'll need to call the customer service or member service number on your card and ask them.

@@p1Sz I copied that information from the company website; I think it was on the main page.

BLISCare What Can BLIS do for you? Provide you with peace of mind BLISCare works behind the scenes with the hospital and surgeon, like a ‘factory warranty’ (comes with what you bought) rather than traditional insurance. While it is not health insurance for a patient, BLISCare is an insurance coverage plan that protects patients from complication related medical expenses. BLISCare pays for all medical expenses, authorized by an approved BLIS bariatric surgeon, caused by possible complications related to the weight loss surgery. Patients who have BLIS care and experience complications will have no financial responsibility for complication related care. Covered complications include: Cardiopulmonary Thromboembolic Bleeding Infection Leak Perforation Stenosis Band Specific complications For more information on pricing, click here. The length of protection is typically a 90 day global period; however, patients may opt to add additional protection for up to 18 months. BLISCare coverage applies during the Claim Period which may vary from 90 days to18 months. Complication must be reported during the Claim Period. Reimbursement continues up to 365 days past the Claim Period. The maximum paid benefit (on per patient/case basis) varies $25,000 (LAGB) to $100,000 (RNY/Sleeve) Range. Premiums vary based on selected protection packages.

Find out their definition of "elective". Just because they exclude the surgery from coverage doesn't mean it's elective.

Not sure why they think the letter "H" followed by the letter "M" followed by the letter "O" should be censored, but that's what the censored words are above, the abbreviation for Health Maintenance Organization.

Okay, I'm going to give you lots of information, some of which you may already know. Your insurance is Blue Cross Medi-Cal HMO. That means that a primary doctor is assigned to coordinate your care. Look on your insurance card and see if there is a pcp assigned to you (it will be printed on the card). If so, call them and make a "new patient get-acquainted" appointment. If there is no one on your card, you have two choices. The first is to start calling doctors off their provider list and ask if they are taking new Blue Cross Medi-Cal patients. The second, particularly if you strike out with the first, is to call the customer service or member service number on your card and tell them you are having difficulty finding a primary care doctor and you need their help. They will help you with this. At your first appointment with your new primary care provider (PCP), tell the doctor that you had the surgery and you would like a referral to a surgeon who will follow you post-operatively. Then one of two things will happen. The first is that they will refer you to someone - a pcp that takes your insurance will know who else takes your insurance. When you have an HMO, your pcp refers you, you don't self-refer (except in a few narrow cases such as gynecology and mental health). The second possibility is that the doctor may have a particular interest in bariatrics and may say that they would like to follow your care themselves. Since you are close to a year out from surgery, this part will most likely not apply to you. I haven't looked up the "global period" for the surgery. Every surgery has a global period where ROUTINE post-op care is included in the payment for the surgery. This means unless you have a complication, your surgeon is NOT paid for the after-surgery visits. Every global period is different, but I am unaware of any that are a year long (which means I don't think this applies to you). For anyone else who finds themselves in this situation, closer to their surgery date, they may find that another surgeon is reluctant to take them on as they will only get paid for the first visit and then none others until you are out of the global period, unless there are complications. I hope this helps.

Just wanted to stop in and give my support. In addition to the other things going on in life, most of the country is going thru a cold spell with less sunlight. That can certainly exacerbate the feelings you are talking about.

What exact type of insurance do you have? You said Medi-cal + Anthem. Is that Anthem primary and Medi-Cal secondary? Is the Anthem product a Medi-Cal replacement plan? Is it an individual policy, or a group policy? Is it on or off the exchange?

No, no, no. If you pray for strength then you also have to pray for bail money. Pray for patience instead. My gut reaction to the condescension in the original post was something along the lines of, "it must be difficult wearing that cloak of condescension every day. Glad I'm not you."

More info: When there is a National Coverage Determination, there is sometimes a Local Coverage Determination (LCD), which overrides the NCD. I did find an LCD for one Medicare geographic area, that does cover VSG. Without knowing your city or state, I don't know if there is an LCD for your area.

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Medicare has a National Coverage Determination (NCD) that covers bariatric surgery. This means it does not matter which state you live in, the coverage and requirements are the same. If you're googling, it's NCD Number 100.1 (one hundred point one). Here is the NCD: Item/Service Description A. General Bariatric surgery procedures are performed to treat comorbid conditions associated with morbid obesity. Two types of surgical procedures are employed. Malabsorptive procedures divert food from the stomach to a lower part of the digestive tract where the normal mixing of digestive fluids and absorption of nutrients cannot occur. Restrictive procedures restrict the size of the stomach and decrease intake. Surgery can combine both types of procedures. The following are descriptions of bariatric surgery procedures: 1. Roux-en-Y Gastric Bypass (RYGBP) The RYGBP achieves weight loss by gastric restriction and malabsorption. Reduction of the stomach to a small gastric pouch (30 cc) results in feelings of satiety following even small meals. This small pouch is connected to a segment of the jejunum, bypassing the duodenum and very proximal small intestine, thereby reducing absorption. RYGBP procedures can be open or laparoscopic. 2. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) BPD achieves weight loss by gastric restriction and malabsorption. The stomach is partially resected, but the remaining capacity is generous compared to that achieved with RYGBP. As such, patients eat relatively normal-sized meals and do not need to restrict intake radically, since the most proximal areas of the small intestine (i.e., the duodenum and jejunum) are bypassed, and substantial malabsorption occurs. The partial BPD/DS is a variant of the BPD procedure. It involves resection of the greater curvature of the stomach, preservation of the pyloric sphincter, and transection of the duodenum above the ampulla of Vater with a duodeno-ileal anastamosis and a lower ileo-ileal anastamosis. BPD/DS procedures can be open or laparoscopic. 3. Adjustable Gastric Banding (AGB) AGB achieves weight loss by gastric restriction only. A band creating a gastric pouch with a capacity of approximately 15 to 30 cc’s encircles the uppermost portion of the stomach. The band is an inflatable doughnut-shaped balloon, the diameter of which can be adjusted in the clinic by adding or removing saline via a port that is positioned beneath the skin. The bands are adjustable, allowing the size of the gastric outlet to be modified as needed, depending on the rate of a patient’s weight loss. AGB procedures are laparoscopic only. 4. Sleeve Gastrectomy Sleeve gastrectomy is a 70%-80% greater curvature gastrectomy (sleeve resection of the stomach) with continuity of the gastric lesser curve being maintained while simultaneously reducing stomach volume. It may be the first step in a two-stage procedure when performing RYGBP. Sleeve gastrectomy procedures can be open or laparoscopic. 5. Vertical Gastric Banding (VGB) The VGB achieves weight loss by gastric restriction only. The upper part of the stomach is stapled, creating a narrow gastric inlet or pouch that remains connected with the remainder of the stomach. In addition, a non-adjustable band is placed around this new inlet in an attempt to prevent future enlargement of the stoma (opening). As a result, patients experience a sense of fullness after eating small meals. Weight loss from this procedure results entirely from eating less. VGB procedures are essentially no longer performed. Indications and Limitations of Coverage B. Nationally Covered Indications Effective for services performed on and after February 21, 2006, Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries who have a body-mass index ≥ 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. These procedures are only covered when performed at facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect on February 15, 2006). Effective for services performed on or after February 12, 2009, the Centers for Medicare & Medicaid Services (CMS) determines that Type 2 diabetes mellitus is a co-morbidity for purposes of this NCD. A list of approved facilities and their approval dates are listed and maintained on the CMS Coverage Web site at http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/Bariatric-Surgery.html, and published in the Federal Register. C. Nationally Non-Covered Indications The following bariatric surgery procedures are non-covered for all Medicare beneficiaries: Open adjustable gastric banding; Open and laparoscopic sleeve gastrectomy; and, Open and laparoscopic vertical banded gastroplasty. The two previous non-coverage determinations remain unchanged - Gastric Balloon (Section 100.11) and Intestinal Bypass (Section 100.8).

When they said "whatever is owed to the office has to be paid before the procedure is done," do they mean your balance has to be paid off or do they mean you have to prepay the procedure? If the former, then if your insurance allows $75 for each office visit, for example, then you would have to pay $75 each visit until your surgery (I doubt you would rack up $4000 in office visit charges). Generally, a deductible is what you pay before the insurance pays. That can mean different things for different policies. Here are some examples, the first one is my own policy: 1. Office visit copays are $35, and the deductible does not apply. Everything else has a $1250 deductible (xrays, tests, etc.). Once the $1250 deductible is met, my insurance covers 70% and I pay 30%. The total I ever have to pay in one year is $5000, then insurance pays 100%. 2. The patient pays $4,000 in deductible before insurance pays a dime. 3. The first three office visits in a calendar year are $25 each, then the patient has to meet a deductible of $2,000, then the insurance pays 80% and the patient pays 20%. So as you can see, depending on the terms of your policy, your deductible may work in different ways.