WLS and Insurance Coverage

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Reviewing Your Insurance Policy or Employer Sponsored Medical

Benefits Plan

There are two ways you could be covered for medical insurance:

You either have an insurance policy that you pay for yourself, or

that is paid in full or in part by your employer (known commonly as

a fully-insured policy).

Or, you may be covered by an employer's self-insured medical

benefits plan (known commonly as a self-insured policy).

If the plan is sponsored by your (or you are a dependent for a

spouses or parent's) employer's plan, then how they pay for the plan

is key to who makes the decisions on the treatment of obesity, and

what the appeal process is for denials.

It also affects which documents control the coverage in the plan. If

the plan is fully-insured, then the key document is the insurance

policy. The insurance policy may also be called a Certificate of

Coverage or Summary of Benefits. If the plan is an employer's self-

insured benefit plan, then the key document is the plan document,

which is usually communicated in the form of a Summary Plan

Description (SPD).

Another key difference is that fully-insured policies are governed

by your state insurance commission, while an employer's plan (self-

insured) is governed by the Federal Government through the Employee

Retirement Income Security Act (ERISA) laws and regulations. These

differences may affect how you approach your insurance provider and

employer in this process.

Fully-insured vs. Self-insured

If the employer plan is fully-insured, the insurance company is

ultimately responsible for the healthcare costs, and the employer

typically purchases a standardized package of coverage.

If the plan is self-insured, the employer is ultimately responsible

for the healthcare costs, and therefore can customize the plan to

include and exclude specific coverage, such as bariatric surgery

coverage.

Fully-Insured

If you are covered by a fully-insured policy, you will need to begin

the process by assessing your insurance policy. To do this, first

you need to request the policy/contract. These documents can either

be provided from your employer or insurance company. These documents

are written in a legal style format and may be difficult to

understand.

Self-Insured

If the plan is self-insured by an employer, you should have a copy

of the plan's Summary Plan Description, which will provide you with

a better understanding of what the plan covers. If not, request a

copy from your human resources department. (Many large employers

have benefits Web sites where all of the plan documents can be

found.)

These documents explain your enrollment with the provider, such as

whether you are enrolled in an HMO, PPO or indemnity plan. In

regards to morbid obesity management exclusions, request that your

insurance provider highlight the sections in your plan that discuss

the exclusions and mail you a copy. If the insurance representative

refuses to do this, thank them for their time, hang up and call

again.

If your employer is self-insured, you may want to write them a

letter explaining how this disease has affected your life. Please

click here for a sample letter.

Policy Exclusion Example

Weight control services including surgical procedures, medical

treatments, weight control/loss programs, dietary regimens and

supplements, appetite suppressants and other medications; food or

food supplements, exercise programs, exercise or other equipment;

and other services and supplies that are primarily intended to

control weight or treat obesity, including Morbid Obesity, or for

the purpose of weight reduction, regardless of the existence of co-

morbid conditions.

Policy Inclusion Example

The Plan will cover the surgical treatment of obesity if the patient

is morbidly obese and if the surgery is performed by a practice

certified by the Surgical Review Corporation (SRC).

In addition, your policy might even have some general exclusion

language in one part of the plan and specifically allow the surgery

in another. For example:

Expenses Not Covered

The medical plan does not cover the following expenses:

• any services or supplies not specifically listed under covered

expenses

and

• treatment or surgery for obesity, weight reduction or weight

control unless the patient is severely obese and suffers from a

related medical condition. Pre-treatment approval is necessary. The

only procedures currently allowed are Vertical Banded Gastroplasty

and Gastric Bypass (GBP)/Gastric Bypass with Roux-en-Y.

Severe obesity is defined as having a Body Mass Index (BMI) of 40 or

greater or a BMI of 35 or greater with related medical conditions.

Related medical conditions include, but will not be limited to:

arthritis, diabetes, hypertension, cancer, liver and gallbladder

disease, and cardiovascular disease.

• treatment or surgery to reverse any procedures performed to treat

obesity, weight reduction or weight control unless medically

necessary

Covered Expenses

• treatment or surgery for obesity weight reduction or weight

control if the patient is severely obese and suffers from a related

medical condition. Severe obesity is defined as having a Body Mass

Index (BMI) of 40 or greater or a BMI of 35 or greater with related

medical conditions. Related medical conditions include, but will not

be limited to: arthritis, diabetes, hypertension, cancer, liver and

gallbladder disease, and cardiovascular disease. The only procedures

currently allowed are Laparoscopic Adjustable Gastric Banding (LAGB)

and Gastric Bypass (GBP)/Gastric Bypass with Roux-en-Y.

• medically necessary treatment or surgery to reverse procedures

performed to treat obesity, weight reduction or weight control

Take your time, and read your policy carefully. As you can see,

sometimes the wording may appear confusing or misleading. If you

require further clarification of your policy exclusions, do not

hesitate to contact your insurance provider or benefits manager and

discuss your plan in more detail.