I am new to the forum and just beginning my journey towards WLS. I just found out my husband's insurance (Aetna Choice Pos II) covers the procedure and will switch to his provider at the end of the year. I have already selected my doctor and they have begun the process of meeting all the requirments for the Aetna insurance plan. Once I switch providers they will submit the paperwork for approval. I sent an email to Aetna asking them about the coverage. Below is the response from the insurance company.

I have two questions if anyone is familiar and can offer answers:

1. Does this mean I will only pay a maximum of $5,750.00 before the deductable?

2. Is the maximum including doctor and hospital fees?

I plan on also sending my questions to Aetna too. I've enjoyed so many of your inspiring stories and look forward to posting on my success.

Thanks!

This is in response to your inquiry on your coverage for weight loss

surgery.

Your benefits

Your plan includes coverage for in-network and out-of-network services.

In-network benefits apply:

* Your deductible is $750.00 per calendar year.

* When your deductible has been met, the plan will pay 50% of the

allowed charges.

* Your plan has an out-of-pocket maximum of $5,750.00 per calendar year.

* Your plan will cover up to a lifetime maximum of $10,000.00 for this

procedure.

* Bariatric surgery is not covered if you will use an out of network

provider.

Your plan also covers obesity preventive counseling at 100% of the

contracted rate, no deductible, and no copayment for in network

providers. You are entitled to have 26 visits per 12 months, of which up

to 10 visits may be used for healthy diet counseling.

The information provided above is not a guarantee of coverage. Coverage

is based on all the terms and conditions of your plan as well as

eligibility at the time services are received.

Of course I'm not expert, but here is my interpretation based on my experience with insurance companies...

If you use an in-network provider, Aetna will pay 50% of the cost of your surgery, up to $10,000, after you've met your $750 deductible.

The way I read it though, they will never pay more than $10,000 for the surgery no matter what, so if their part goes over that, you'll be responsible for the rest no matter what the lifetime maximum is.

For instance, let's say your surgery costs $15,000. You will pay your $750 deductible, leaving $14,250. They will pay 50% of the remainder which is $7125, leaving $7125 remaining. BUT since your max is $5750, you'll pay $5000 of that and they'll take care of the $2125.

So...if I'm interpreting it correctly (BIG IF!), for a $15,000 (total cost including hospital, surgeon fees, anesthesiology, etc.) surgery, you'll pay $5750 and Aetna will pay $9250 (b/c it's under the $10k limit).

Confused?!

I.m with aetna and they paid all of the hospital. I only paid 635 for the classes and vitamins. So just wait till you actually have the insurance then call and ask them.

I would agree with GeauxForIt's interpretation of what you posted. I would STRONGLY recommend you find out what the TOTAL cost of your surgery will be and then try to get it in writing. That might be difficult because they will try to say, subject to .... (complications, etc).... The hospital where I had my surgery submitted a bill for $83K and change, and that was JUST for 2 nights stay and I had NO complications. I have the same type of policy as your husband, but don't have near the limitations as that policy. (The employers get to customize the policies according to the premiums they want to pay on behalf of their employees) Then, my surgeon submitted bills over $20K which was ridiculous if you ask me. Aetna ended up paying $53K for the hospital bill.

You probably already know that there are contracted rates between your surgeon/ hospital/ etc and Aetna. The tough part is there are so many "extra's" that they try to bill for like blood work, medications, use of equipment, etc, etc....

I would be REALLY careful before you schedule your surgery and find out what you might be signing yourself up for because I would hate for you to get stuck w/a bill that could be in the thousands or tens of thousands.

If you have any other questions, feel free to ask and I will try to help however I can.

The way I was told is take your 750 deductible and add it to your out of pocket max 6350 is the max u will pay. But your plan will only pay 10,000 so u need to talk to your surgery coordinator and get some figures because I've seen some big bills that were much more than that.