Insurance doesn't cover WLS :( Now what?

[Mommyto3 2]

Hi everyone. I posted a few days ago asking about how to start. Just got in touch with my health insurance company (Aetna) and am shocked to find out that they don't cover ANY WLS, regardless of co-morbidity. I cannot believe that. I thought we had pretty good coverage.

So what do I do now? I am seriously doubting that we can afford self-pay with 3 kids at home to consider.

Hubs said that open enrollment is in June for his company and maybe another plan his company offers does cover WLS?

So... a couple of questions for those of you with far more experience in this than me...

~If I begin a physician monitored weight loss plan now then am able to switch to a different plan that will cover the surgery in June, do you think the insurance company would accept those 6 months of monitoring for the prerequisite?

~What if hubs' company doesn't have ANY plans that cover WLS? What then?

[AmandaRaeLeo 2,145]

I'm a self pay headed to Mexico in March. My insurance excludes WLS too.

Amanda Rae

[Mommyto3 2]

Amanda, how much is your Mexico surgery? Does it make you nervous to have surgery in another country? It does for me!

[PdxMan 4,292]

My insurance didn't cover it either, so I headed to Las Vegas for self-pay. $10,400

I took a second on the house to pay for it and have already realized that much in savings from medical costs and food. Have it all paid off.

You say you have 3 kids at home to consider ... do you mean that you can't afford to have the surgery because of having 3 kids at home or you cannot afford not to have the surgery because of 3 kids at home?

I have 2 young kids at home and I couldn't afford NOT to have the surgery.

[theshrinkingchef 61]

Definitely do the monitored weight loss. It's usually the company that either ops in or not. Did you call aetna to see if that is the case? It may be your husbands company not the insurance itself. My Sisnlaw told me her company encourages weight loss through diet and exercise and will not cover wls. A lot of people try self pay to Mexico. There's a lot of info about it on here. Be careful and do your research! Good luck! You're lucky his open season is in June and not November! Hopefully it will all work out for you! Fingers crossed!

[Bree 65]

Mexico or bust, baby. Mine wouldn't cover it either.

I'm paying about $8750, all inclusive, for March Surgery in Mexicali. However there are good Mexico surgeons who will do it for as little as 4K-5K.

[lucky8mb1 167]

Mine covers nothing for WLS, either. While I think the MX surgery options are wonderful, I was too nervous to do it myself. I explored local surgeons and found pricing in my area to be rather reasonable compared to other areas of the US. I paid $12k in the Houston area.

I used some bonus money and some savings to pay for it.

[AmandaRaeLeo 2,145]

Amanda' date=' how much is your Mexico surgery? Does it make you nervous to have surgery in another country? It does for me![/quote']

$5000. I am nervous naturally but I did a ton of research before I decided on my surgeon. I am going through A Lighter Me which is an American company that facilitates surgery in Mx.

Amanda Rae

[NurseGrace 509]

welp it seems to me that you really have three options.

1) start a monitored dieting program. Most insurances require it so go ahead and do that.

2) look into purchasing other insurances that DO cover it and see if that is financially a practical thing to do for your family.

3) start looking at self pay more seriously just in case that is the most realistic option for you.

I don't think this is something people should really go DEEP into debt for, but thats just me.

[Mommyto3 2]

Thank you all for the responses, I appreciate all the ideas!

Going into debt for this is not a viable option for us at this time.

Good advice on checking about the company plan, I hadn't even thought of that.

Another idea I have is to check my own company's benefits. At this time I do not opt in to health insurance for my job (I teach virtual school) because the coverage under my husband was already in place when I started here. But I believe our open enrollment will be in May and if they offer WLS that could be an option as well.

Again, I appreciate any and all suggestions Everyone is on a journey here and how we get there is not as important as arriving at our destination!

[firelle 146]

My Aetna insurance didn't cover any WLS either. First thing I did was talk to my employer's HR and ask them if this was something they would consider adding to the plan. They were kind enough to look into it for me and see about purchasing the rider that would add WLS to the plan. Unfortunately, our company is too small to even be offered that rider. There was just no way. They sent me all the email communication about it so I could sew for myself.

Next, I looked at my husband's Anthem BSBC of Cali. He and I called their member services line and spoke to a representative who said it is indeed covered. They also showed me where to look online to see their medical policy for WLS (it shows which surgeries are covered, and what conditions you must meet, like BMI over 40 and a list of acceptable comorbidities). His open enrollment period was in Dec.

Then I called the insurance coordinator at the surgeon's office and told her my situation, that I would be covered starting Jan. She said it doesn't matter to insurance if I complete the prerequisites before getting on their plan or not.

So I started the monthly nutritionist appointments in August. They were only $30-$60 per visit, but my Aetna ended up covering them! Aetna also covered the initial surgeon consult, even tho they don't cover WLS itself. They did not cover the psych eval, so I had to pay $380 out of pocket. They let me set up a payment plan. I know that's a high rate, as I've seen other people's evals cost $200-$250.

In Dec, my husband added our daughter and I to his plan, and verified that there's no waiting period for pre-existing conditions. I got my new insurance card at the beginning of Jan, and my info was submitted to my new ins on the 11th. Still waiting for approval, but the ins coordinator said everything is good.

Hope this helps! I also decided to change surgeons, so all my nutritionist appts and psych eval were forwarded to the new surgeon. I had a consult with him at the beginning of Jan and the new ins covered it.

[pacificpeach 32]

My insurance didn't cover it either, so I headed to Las Vegas for self-pay. $10,400

I took a second on the house to pay for it and have already realized that much in savings from medical costs and food. Have it all paid off.

You say you have 3 kids at home to consider ... do you mean that you can't afford to have the surgery because of having 3 kids at home or you cannot afford not to have the surgery because of 3 kids at home?

I have 2 young kids at home and I couldn't afford NOT to have the surgery.

[pacificpeach 32]

^{Hi PDXMan!}

^{I am also headed to Las Vegas to see Dr Umbach!!! Can you tell me how your experience was? I am having my surgery in March.}

[NikkiV1986 121]

I'm in Vegas and I'm paying cash too! $11000 for me. Most of it is care credit which I can pay monthly....

[newat52 1,612]

Hi everyone. I posted a few days ago asking about how to start. Just got in touch with my health insurance company (Aetna) and am shocked to find out that they don't cover ANY WLS, regardless of co-morbidity. I cannot believe that. I thought we had pretty good coverage.

So what do I do now? I am seriously doubting that we can afford self-pay with 3 kids at home to consider.

Hubs said that open enrollment is in June for his company and maybe another plan his company offers does cover WLS?

So... a couple of questions for those of you with far more experience in this than me...

~If I begin a physician monitored weight loss plan now then am able to switch to a different plan that will cover the surgery in June, do you think the insurance company would accept those 6 months of monitoring for the prerequisite?

~What if hubs' company doesn't have ANY plans that cover WLS? What then?

Sorry to hear that you don't have coverage. The question to ask is the benefit department "Is WLS specifically excluded?" We took the highest coverage possible but the exclusion comes from the HR at the company. What is essentially means is no matter what, your company has asked for and received and exclusion for this type of coverage regardless of medical need in order to keep premiums lower. I just went through the digging and that is my bottom line. Therefore I am self pay. Most of the Docs. have a medical finance company that will work with you. I am very blessed that I can come up with the money. Having and empty nest and no debt outside of a mortgage helps. I am scheduled for surgery on Feb. 20th. I believe it will be money well spent. My dr. has an all inclusive price so it's good to know there will no surprises. having my surgery done in Dallas.

Good luck to you. Hope you find a way to get 'er done!