How to get information before acquiring specific insurance

[AmandaD. 35]

Hello everyone!

Currently I am not under my employers insurance plan yet. They list three different companies/plans:

• Aetna Choice POS ii (open)
• Blue Cross Blue Shield PPO
• United Healthcare Choice plus

I am trying to get more information in the months to come on specifics (pre op requirements, if I need to go to a "center of excellence", etc.) I spoke to my job's HR dept. and they only gave me their medical benefits PDF which includes a very vague breakdown of their own requirements (BMI over 40, nutritionist, psych, physical commitment) other than that they just state to add whatever requirements are listed on the specific insurance policy. I thought it would be as easy as just calling these three companies and asking them their requirements based off of specific plans and I keep getting the run around. Most state that they can assist until I have enrolled so they can see specifics, but my jobs HR states I should be able to call and ask ahead of time.

Do I need to wait until I enroll? I was hoping to call each company so I can compare/contrast pros/cons (I would prefer only needing 3 months of dietician, etc. rather than 6, etc.) but it seems I have to just (sort of) blindly pick one and hope for the best? I guess I assumed that each plan has it's own specific requirements set it stone, and then possible other ones that my job may add in... just seems a lot more difficult to try to get everything organized before diving in.

Thank you!!

[SpartanMaker 676]

Sorry you're having trouble getting the info you need. It might be that all the plans require the same pre-op stuff?

In my experience, it's the employer, not the insurance plan that ultimately determines coverage requirements. For example, I currently have United Healthcare Choice Plus-HSA and had the same thing with my previous employer. One wanted six months of dietitian visits and the other only three months.

[KimA-GA 540]

6 hours ago, AmandaD. said:

Ask if there is a bariatric exclusion or allowance to the insurance broker handling your insurance for your company.

Many (most)insurance plans have an exclusion for bariatric surgery meaning that it will not cover it at all. My main insurance through my employer is is unitedhealth choice plus and there is an exclusion to bariatrics on out policy so I have zero coverage through my primary insurance. My husbands insurance allowed bariatrics for the first time this year to members and he put me on his insurance and I will be able to have covered surgery.

[AmandaD. 35]

On 08/06/2022 at 00:33, KimA-GA said:

Ask if there is a bariatric exclusion or allowance to the insurance broker handling your insurance for your company.

Many (most)insurance plans have an exclusion for bariatric surgery meaning that it will not cover it at all. My main insurance through my employer is is unitedhealth choice plus and there is an exclusion to bariatrics on out policy so I have zero coverage through my primary insurance. My husbands insurance allowed bariatrics for the first time this year to members and he put me on his insurance and I will be able to have covered surgery.

I have looked at the breakdown of my jobs medical insurance policy and it says that it covers medically necessary Bariatric surgery 80%. So I know it’s covered (for the most part). I was just hoping to get the break down on what the individual insurance policies include for pre op requirements, etc. My jobs break down is very vague. All it says is that it covers it if the BMI is 40+ and I get nutritionist and psych eval… then it says “and also complete what the insurance provider states…” but I can’t get specifics I guess until I enroll?? Thank you!

[BigSue 1,328]

Have you picked a surgeon or clinic? If so, you could try asking them — they should be very familiar with dealing with insurance companies. My surgeon’s clinic has a “patient navigator” whose job is basically to help patients through the pre-op process. She looked up my insurance and told me exactly what the requirements were. Of course, that’s easier if you already have insurance so they can get your actual policy, but if you work for a large company, chances are good that your surgeon has other patients with the same insurance and know what the requirements are.

[AmandaD. 35]

On 08/06/2022 at 02:36, BigSue said:

Have you picked a surgeon or clinic? If so, you could try asking them — they should be very familiar with dealing with insurance companies. My surgeon’s clinic has a “patient navigator” whose job is basically to help patients through the pre-op process. She looked up my insurance and told me exactly what the requirements were. Of course, that’s easier if you already have insurance so they can get your actual policy, but if you work for a large company, chances are good that your surgeon has other patients with the same insurance and know what the requirements are.

My insurance is strict with who they allow, but I can’t get a list of approved in network surgeons until I pick a policy I guess - which is annoying I wish there was a way to get all of this information before hand so you can research.

[RickM 1,747]

Most insurance companies will have a "policy bulletin" (or some such term, that was Aetna's) for weight loss or bariatric surgery on their website that spells out the details of their requirements to qualify. BMI of 40, or 35 with certain comorbidities, and a psych evaluation are pretty much industry standards - they all do that. More specifically, they will get down to what procedures they cover (and maybe some that they specifically do not) and what other hoops they want you to jump through - a three or six month diet program of some kind is fairly normal, but not always, and they will spell out what they require from those. Some companies or policies may limit you to one bariatric procedure for a lifetime, and others don't.

Beyond that, your surgeon or PCP may have other requirements to sign off on depending upon your health history - clearance from a cardiologist, pulmonologist or other specialist - and the surgeon or hospital program may have specific diet requirements or nutrition classes of their own.

While being eager to get this over with, I wouldn't necessarily shy away from a six month diet requirement, depending upon how it's structured. Done well, either with a good RD's guidance or self guidance, correcting old bad dietary habits and establishing new healthier ones pays off in the long run, as that is really what helps to keep the weight under control in the years ahead; a quickie diet to lose a few more pounds (maybe) the first couple of months or pre-op isn't of much long term value.