Hi everybody!<br /><br />I hate people who jump on to message boards and ask questions they could suss out for themselves with some research, but I'm desperate!<br /><br />This is our annual chance to change our health plans at work. I'm in Seattle, currently on the Group Health H.M.O. which, needless to say, does not cover bariatric surgery of any kind under any circumstance.<br /><br />However, there are two Blue Shield PPO plans listed, a "high" and "low" one depending on the amount of coverage you want to receive. The brochures I got at work don't have any detailed information about exclusions and limitations, though. Just cost.<br /><br />After doing my research on doctors, I've decided that I want to go to Dr. Quebbermann in Newport, CA, because he seems to be the leading US bariatric surgeon and because my family is in O.C. and it will be easier for them to care for me there than have them come to me in Seattle.<br /><br />So here are my questions:<br /><br />1. Do PPOs let you travel to doctors "in-network" but out of state? Dr. Quebbermann has Blue Shield listed as an insurer on his website, but I know there are hundreds of plans within Blue Shield, all of which have exclusions attached.<br /><br />2. If I stick with my H.M.O. and pay cash for the surgery, will my H.M.O. be invalidated? Will it cover me if I have a complication? I've seen horror stories here about month-long stays in the ICU. I can pull together enough money for the surgery, but not six figures for a month-long hospital stay and extra corrective surgeries.<br /><br />I've called both the P.P.O. and H.M.O, but they've been cagey about giving me clear answers. They obviously want to keep people confused and off-balance as to minimize claims. Any info that anybody might have would be incredibly helpful!

I would encourage you to contact your HR Rep and ask them if you can speak with the person in your company who is the contact for your insurance administration. You don't have to give them specific details, but explain to them that you are trying to make the best decision for you and/or your family but need more information that what has been provided in the booklets specific to coverages/ exclusions.

You are right, each plan is going to vary- especially because employers can elect to add/ exclude things for the very same policy which is why everyone has a unique group ID#/ policy#.

I know what you are going through because while they do give you a nice overall view of the benefits, it's the fine print that can really be a problem for some people. Seriously, contact your HR rep and ask them for who you can talk to- maybe they can provide you with a contact at those other insurance companies.

I wish you luck!

Traveling outside your state with BCBS PPO and going to a different plan Washington is your home plan (assuming) so California would be Blue Card. You can do this. Some plans pay for Bariatric and some don't. Is the *** also BCBS? If so, it is possible your plan excludes Bariatric completely. There should be a number somewhere you can call with coverage questions - if you can't find it or aren't getting answers as you mention, ask someone in your HR department if you can see a benefits book. They may have one to look at but just don't give them out if you don't have that plan. You have to have access to what they cover - otherwise you can't make an informed choice. Many times your employer selects what is and isn't covered so the HR department may be able to just tell you. As far as covering complications? I have heard people say yes it was covered and no it wasn't so who knows. Also someone mentioned recently their insurance requires you have it for 2 years before it covers Bariatric, Vital info you need to know! Good luck!

<br /><br />After doing my research on doctors, I've decided that I want to go to Dr. Quebbermann in Newport, CA, because he seems to be the leading US bariatric surgeon and because my family is in O.C. and it will be easier for them to care for me there than have them come to me in Seattle.<br /><br />So here are my questions:<br /><br />1. Do PPOs let you travel to doctors "in-network" but out of state? Dr. Quebbermann has Blue Shield listed as an insurer on his website, but I know there are hundreds of plans within Blue Shield, all of which have exclusions attached.<br /><br />2. If I stick with my H.M.O. and pay cash for the surgery, will my H.M.O. be invalidated? Will it cover me if I have a complication? I've seen horror stories here about month-long stays in the ICU. I can pull together enough money for the surgery, but not six figures for a month-long hospital stay and extra corrective surgeries.<br /><br />I've called both the P.P.O. and H.M.O, but they've been cagey about giving me clear answers. They obviously want to keep people confused and off-balance as to minimize claims. Any info that anybody might have would be incredibly helpful!

Your BCBS "home plan" should have a website with their policies. Look for Medical Policies or search on "Bariatric Surgery." Most CSR's don't really know what the policies are. For PPO plans, you can go t any BCBS provider, regardless of location, but the home plan policies dictate the coverage.. If you have the name of your BCBS carrier, I can help you locate and interpret your requirements. (I've been in the medical.insurance industry for 30 years).

Don't forget- her employer may have excluded certain aspects of the traditional coverage provided and that won't be known unless she goes through her HR/ Benefits Dpt to be sure she is getting the most accurate information.

Your BCBS "home plan" should have a website with their policies. Look for Medical Policies or search on "Bariatric Surgery." Most CSR's don't really know what the policies are. For PPO plans, you can go t any BCBS provider, regardless of location, but the home plan policies dictate the coverage.. If you have the name of your BCBS carrier, I can help you locate and interpret your requirements. (I've been in the medical.insurance industry for 30 years).

I am going to attend an information session tomorrow that I registered for with this same doctor. A staff member I've been talking to at Dr. Q's office told me that if there are complications, and it is medically necessary to have further treatment, insurance should cover it. My insurance does not cover any of the surgery so I will self pay. Like you, I can pay for the surgery, but not a six-figure hospital stay. I plan on asking this question again tomorrow.

Hi Veda!

I guess by now you'll have attended the information session. May I ask what kind of impression you had of the staff? I've heard nothing but good things, but more information is always better than less!

Also, if it's not too personal, may I ask if they quoted you a self-pay price, and if so, how much it was for?

They don't seem to want to quote any prices without first subjecting you to a big pitch. But I'm already sold on the surgery, so don't really care about the sales pitch. I just want to know how much it's going to be, period.

I understand if that's too personal a question, and please forgive me if it is.

<br />I am going to attend an information session tomorrow that I registered for with this same doctor. A staff member I've been talking to at Dr. Q's office told me that if there are complications, and it is medically necessary to have further treatment, insurance should cover it. My insurance does <u>not </u>cover any of the surgery so I will self pay. Like you, I can pay for the surgery, but not a six-figure hospital stay. I plan on asking this question again tomorrow.<br />

<br /><br /><br />

Thanks VBG!

I contacted my HR rep, but she didn't have access to any of the contracts or anything. She suggested that I call the customer service number for our insurance company. Hmm.

I did find out that our PPO plan, Blue Shield of Washington is apparently under an umbrella of Blue Shield of California, which theoretically would give me access to Dr. Quebbermann, if the PPO covers bariatric stuff.

I waited on hold *forever* Monday morning, but I'm going to call back today.

Thanks for the info! I didn't know that employers could modify the policy to exclude specific things!

<br />I would encourage you to contact your HR Rep and ask them if you can speak with the person in your company who is the contact for your insurance administration. You don't have to give them specific details, but explain to them that you are trying to make the best decision for you and/or your family but need more information that what has been provided in the booklets specific to coverages/ exclusions. <br /><br />You are right, each plan is going to vary- especially because employers can elect to add/ exclude things for the very same policy which is why everyone has a unique group ID#/ policy#. <br /><br />I know what you are going through because while they do give you a nice overall view of the benefits, it's the fine print that can really be a problem for some people. Seriously, contact your HR rep and ask them for who you can talk to- maybe they can provide you with a contact at those other insurance companies.<br /><br />I wish you luck!<br />

<br /><br /><br />

Hi MeMeMEEE!

My HR person did confirm that we're under the Blue Shield of California umbrella. She didn't know much else and referred me to the basic customer service number for BSBC. She didn't give me the group policy number or anything, but I presume that they'll be able to look it up.

I was kind of hoping I'd be able to avoid doing this over the phone, because I'd like to have proof of coverage (if there is any) in writing. But what can you do?

Unfortunately, the H.M.O. is an entirely different program unaffiliated with BCBS. I actually like my H.M.O., so that's a bummer.

Thanks for the tip about having the insurance for two years, by the way. That's vital info!

<br />Traveling outside your state with BCBS PPO and going to a different plan Washington is your home plan (assuming) so California would be Blue Card. You can do this. Some plans pay for Bariatric and some don't. Is the *** also BCBS? If so, it is possible your plan excludes Bariatric completely. There should be a number somewhere you can call with coverage questions - if you can't find it or aren't getting answers as you mention, ask someone in your HR department if you can see a benefits book. They may have one to look at but just don't give them out if you don't have that plan. You have to have access to what they cover - otherwise you can't make an informed choice. Many times your employer selects what is and isn't covered so the HR department may be able to just tell you. As far as covering complications? I have heard people say yes it was covered and no it wasn't so who knows. Also someone mentioned recently their insurance requires you have it for 2 years before it covers Bariatric, Vital info you need to know! Good luck!<br /><br /><br /><br />

<br /><br /><br />

HI Janea!

Thanks so much for your offer to help out! My HR person gave me the basic BCBS toll-free number to call. I tried Monday morning, but after being on hold forever I gave up. I'm calling back today (Tuesday) to get more information, hopefully it'll be less busy after the weekend.

I think our name is Blue Shield of Washington State, but the HR person said we're under the umbrella of Blue Shield of California. Kinda confusing.

I will certainly get back to you with more information! Thanks so much!

<br />Your BCBS "home plan" should have a website with their policies. Look for Medical Policies or search on "Bariatric Surgery." Most CSR's don't really know what the policies are. For PPO plans, you can go t any BCBS provider, regardless of location, but the home plan policies dictate the coverage.. If you have the name of your BCBS carrier, I can help you locate and interpret your requirements. (I've been in the medical.insurance industry for 30 years).<br />

<br /><br /><br />

I got a reply back from my HR person that basically amounted to, "All I know is that our PPO program is Blue Shield of Washington, under the umbrella of Blue Shield of California. Call the 800-number provided for more information."

It's a bummer, because I really wanted to have any information in writing!

<br />Don't forget- her employer may have excluded certain aspects of the traditional coverage provided and that won't be known unless she goes through her HR/ Benefits Dpt to be sure she is getting the most accurate information.<br /><br /><br />

<br /><br /><br />

I am under a different BCBS, but just letting you know that I never did receive my coverage info in writing. I asked multiple times for a written policy but they would only tell me the Bariatric coverage on the phone. I did get a letter stating that I was pre approved after surgeon submitted codes, etc. However it never listed amounts covered, etc. Very frustrating. Our company policy books only say that it is covered but doesn't go into any details so you have to call to find out.

I'm a black and white kind of girl though and like to see it in writing, so that was a tough one for me.

Well, I did another round of calling, this time with some more specific questions and information, and the BCBS rep said bariatric surgery is covered now! I asked him to triple-check that he was looking at my company's specific plan, and he said that he absolutely was. I asked him to make sure the New Program is in-network, even for an out-of-state patient, and he said that was cool, too. He even read me a huge long list of requirements (six month diet program, consult with dietician, consult with psych, etc.) that the insurance company requires to approve the surgery. I don't think he'd have that if they don't cover the surgery.

He wouldn't send any of it in writing, though.

Then I called the New Program offices, and Paula (who was very sweet and incredibly informative) pretty much told me all the same things the BCBS rep told me. So it seems like this is going to be a go, unless the insurance rep got it wrong and my company does have a specific bariatric exclusion.

I'm staying skeptical that I got my miracle answers over the phone, but it gives me a direction for what insurance to pick during open enrollment, that's for sure! Spending an extra $600 in premiums this year to potentially save $18,000 is a gamble I'm willing to take!

Thanks to everybody for the tips and advice. When I had some more specific questions to ask, and knew how to ask them, I really got the answers I needed. Thanks to all!