[samhain_1031]

Some backstory:
I live in VA - Shenandoah Valley area. I am a female, soon to be 32 years old. I am 5'7" and have struggled with weight my entire life. No fun at all. I have always had asthma, since the age of two/ Recently I have woken myself up storing, something I have NEVER done before. I am borderline hypertensive.
I am currently the heaviest I have ever been. I do not feel comfortable in my own skin and I won't allow myself to be photographed. I know I'll regret this as I have young nephews and nieces and I won't have any photos of me with them.
When I was 17, I dropped so much weight that one woman remarked that I was going to "disappear" if I didn't stop losing. To clarify, at that time I weighed 160 lbs. which was great for me! That was my high point.
In 2008, I went on the Phen-Pro pill diet and had some success. One girl that I worked with remarked on how much weight I'd lost in such a short period of time. However, this regimen did not leave me feeling the greatest and I had to stop. Needless to say, that weight - and then some - came back.
Funny thing about me is that I actually exercise on a fairly regular basis. I have a gym membership that I use - treadclimber is my favorite. I walk, hike, bike, swim etc. I garden (growing pumpkins for the first time!) I do sit ups, some pilates, free weights. I am still obese.
It was not long ago that I decided to stop lying to myself. I AM BIG ENOUGH TO HAVE WEIGHT LOSS SURGERY. I did research on the different methods on my own and decided that I wanted the Roux-en-Y option. I signed up for an information session at a local hospital and submitted my insurance information to them.
I was heart broken when they told me that my insurance has weight loss surgery as an exclusion on my policy. I really started crying and felt so defeated. I receive insurance through my employer - which is a specific county. We have Anthem and the fact that there would be such an exclusion leaves me dumbfounded.
I have decided to shed my sorrowful attitude.
But I have some questions, especially for those that have undergone this surgery in VA:

Is there a way to make an exclusion an inclusion by paying extra on a pre-existing policy?
Is there a "best" insurer to try to get insurance through? By "best" I mean the one with the lesser waiting period, for both coverage to kick in and surgery (I know some require 6-12 months of supervised diet,etc), the most coverage, etc...
Would it be more cost efficient to try to self pay on a payment plan or attempt to get insurance that covers WLS?
Does anyone know of hospitals/bariatrics in VA that offer self pay through the institution itself instead of something like CareCredit? I've heard this exists, but the hospital that I went to made no such mention of this.

ANY help that anyone can provide would be much appreciated!

[not quite Barbie]

Hi, I just want to welcome you, though I don't have any answers to your questions. I'm thinking the RNY costs about $30,000 so it would be a good idea to talk to your insurance company and see if there's a way to pay to get it put on your policy. Any chance of finding a second job (or chaninging your first job) to someone that has the right coverage?


I think CareCredit will give you an interest free loan for one year, but if you can't pay it off in one year then they really sock it to you, so look into alternatives. Can you get a 2nd mortgage on your home, or a HELOC? Do you have a current credit card that might let you put a chunk on it? Can you get a personl line of credit loan from your bank? Keep in mind that you insurance may also not pay for any complications that might result from the surgery!!!

Good luck and keep trying. It takes some people years to get this surgery, but if you give up then it's never going to happen.

[samhain_1031]

hi not quite Barbie,
I am really trying to do anything that I can. I'm not sure where my insurance is coming from considering that VA is one of six states that has a mandate that WLS must be included as an option unless the insurance is strictly self funded (as opposed to fully funded.) I am going down any avenue that I can.
Thank you for your suggestions. When I went to my information session, they gave us a pamphlet about Care Credit. My feeling on them is that if I could afford their interest rates, I wouldn't need financial assistance! But, if it comes down to that being my ONLY option, I may look in to it.
Thanks again and congratulations to you!

[mj2903]

Samhain,

If you could fill in some stats it would help us to understand where you are coming from. My insurance excludes WLS unless medically necessary but it covered mine based on my BMI, I didn't have any co-morbidities that they considered for the lower bmi requirements.

I don't know how the mandated coverage works but I wish you the best in finding a way to get it covered.

[samhain_1031]

I am 5'7" and weigh 264. That puts my BMI at 41.3.
I don't have high sugar, cholesterol or blood pressure (although this was close at the last dr. visit). I have asthma, back pain, and abnormal menstrual cycles (which my dr. told me is likely due to excess weight.)

[mj2903]

You can enter your stats at user CP, then edit profile. - that way you won't get asked repeatedly for them.

So according to industry standards, (not insurance company) you should qualify with that BMI for the surgery. I also have asthma, arthritis in my back (among other places),fibromyalgia, my blood sugars were fluctuating from normal to low diabetic, my blood pressure had moved from low to the pre-hypertensive area and my knees hurt all the time. None of these were considered co-morbidities with my insurance and if they were they would have had to have been documented for at least 3 years in duration.

From: Insurance coverage for bariatric surgery often limited


Legislation ineffective

Although these laws may lead to greater prevalence of coverage for obesity-related surgery, doctors and patient advocacy groups have complained that legislation is ineffective. “Even if a law mandates that surgery has to be offered by insurance companies as part of at least one plan, it still may not be covered under the patient’s particular plan,” Hutcher said. Insurance companies may circumvent the law by only covering a fraction of the surgery’s costs or reimbursing such a small percentage that hospitals and surgeons cannot afford to perform the surgery, he said.

The article is from 2005 and I don't know if there have been any changes, if the text above is accurate, it just has to be offered, the company doesn't have to purchase a policy that covers it. But it also has some good information that might be useful if you end up requesting a waiver.

I found this site which has some discussion on requesting a waiver of the exclusion. United Healthcare Insurance

[samhain_1031]

thanks mj2903 for all of that information. there really is a lot out there. I really dislike all of this insurance stuff - it seems so difficult for the average non-insurance worker to comprehend.
From what I've heard, co-morbidities are, for lack of a better term, less important if a BMI is over 40. From 35-40 there generally needs to be documented co-morbidities.
It seems to me that insurance companies would want a person to act before there were too many problems. I know they're in the business of making money, or saving money themselves, so it would seem that would b the smart way to go.
Last dr appt I was pre-hypertensive. I'm not going to lie, that shocked me. my blood pressure had always been excellent prior. It also seems that asthma would be considered, giving that a more normal weight can often alleviate many breathing problems.
I definitely need to read more on waivers. Thanks again for your support and assistance!

[mj2903]

Each company has their own co-morbidities that they consider, asthma was not one that my insurance company considered and I have only had major issues the past 2 years with it. Other companies do consider asthma. I had to keep my bmi above 40 to be covered, but considering I gained weight (asthma related meds) on the supervised diet there was no problem there.

My husband if he were to decide to do this he would only need to have the bmi of 35-39 to qualify.

Do you have access to your policy to check the wording on the exclusion? Many companies have them online and my BC company also told me where to look for the specifics that the doctors use (under provider info) and I think the search term was surgical treatment of morbid obesity. I never would have thought to search under provider info without talking to them.

If you have a chance, call and talk to them and see what they say and ask if there are any chances of getting a waiver and how to go about it.

[shakeypuddin10]

samhain -do you know if you have sleep apnea? I went to the pulmonologist today and he said people with sleep apnea can develop heart problems and other morbid conditions unless it is treated and the only true treatment is to lose weight. also, with your abnormal periods, have you ever been diagnosed with Polycystic Ovarian Syndrome? it is a problem that a lot of overweight women have and deals with insulin levels. It plays a huge part in the battle to lose weight and makes it very difficult to lose. just some things to ponder if you have to fight with your insurance. Good luck to you!

[feedyoureye]

This is the wording on my insurance:
Principal Exclusions and
Limitations
The following services and supplies are excluded or limited:
28) Weight control surgery or procedures including without limitation gastric bubble, gastroplasty, gastric bypass, gastric stapling, liposuction and HCG injections; and any Experimental Procedures for the treatment of obesity. However, Medically Necessary services as determined by WHA for the treatment of morbid obesity with Prior Authorization are covered.

It sounds pretty much negative, but the last sentence seems to leaves the door open....My Dr hasn't presented my cast to the insurance co. yet, but they seem to think it will be a good case....The wording still worries me though. Good luck with your case. If I find anything out that might help you, Ill post here....