CA Medi Cal & Partnership surgery coverage.

[NikaChicky 0]

Hi I'm new ! I was referred for WLS, right now I am going thru the motions, waiting to hear from MediCal/Partnership. Are there anyone here that was sucessful having WLS with these forms of CA Medicaid programs??

Sidenote: I am 5 foot 9, current weight 255, recently diagnosed with diabetes type 2 and high cholesteral lipids. I read that to be elegible for Insurance to pay for WLS, I have to diet for 6 months. Will I end up dieting my way from elgibility? My current BMI is I believe 36-37, and the minimum BMI for insurance/surgery is 35......do they count your weight/BMI from the beginning of the program, or from your current weight (after weight loss) ? I hope that someone understands what i mean out there!!

Thanking you in advance for any answers. ♡

[allwet 868]

hey Nika, the requirement is for 6 consecutive appointments with a nutritionist and mine was very clear if you miss 1 appointment you start the 6 over again. Never was a mention of a minimum weight loss in that period.

i cant answer to the chance you might drop below min bmi for surgery cause i was so far above it.

I think i remember that comorbidities lowered the min bmi for approval.

good luck

[NikaChicky 0]

Thank you for the info! ♡

[elforman 234]

@NikaChicky I'm not sure what you mean by MediCal/Partnership. Do you mean one of the situations where a private insurance company like Health Net administers the plan on behalf of the state? Most MediCal recipients are in either a plan like that or what's called a "COH" (County Operated Healthplan). In both cases they are run like any other H-M-O, but because they are the stewards of the public's money, and the members' eligibility can change from month to month, the restrictions and hoops you have to jump through are likely to be a tougher than the standard insurance company protocols. They know that from a financial standpoint it makes more sense to pay for the surgery since it will likely cost less to do that than to treat the diabetes, heart disease and knee replacements that are likely to follow if left untreated. But because the MediCal population is can be transient and unreliable, they will also take extra care to ensure that the member will have a good support system and be able to follow the post-op requirements.

And it just so happens that I work for one of the COHs, so if you have any specific questions I'd be happy to help. If it's something I can't answer I've got resources throughout the company who can answer policy questions.

Edited April 24, 2018 by elforman