I Have Another Insurance Question?

[robs477]

For @DianaCox and @Larra, and anyone else of course. This is the time of year where that we have to make our new insurance selections for the next year at my job and my Wife’s job as well. At my Wife’s job, the insurance there is Aetna and does NOT include Bariatric surgery of any kind for any reason. At my job, the insurance is with Cigna and it does. I have already been pre-approved for my DS surgery that will happen in January, (hopefully), But...and here is my question. My Wife now wants to have WLS, a VSG done in 2015 sometime also, after my DS. IF I add her to my insurance for 2015 at my job which is covered by Cigna, are there any exclusions that you may know of that would prevent TWO weight loss surgeries, hers and mine in one calendar year and or is there any way they can deny her WLS since she will be a new add on to the my Cigna policy? She meets the BMI >40, requirements etc. My company also charges an extra monthly fee of $100 or so to add a spouse that has declined their company provided insurance. That’s no problem of course and is a lot cheaper than paying for a VSG. I didn’t see anything anywhere that would prevent us from doing that? I even called and asked about any limitations, (not bariatric surgery specifically), and the Lady said there are none, her insurance coverage is stand alone for her. I am also attaching the Cigna.pdf for you to maybe look at also. Thank you Ladies so much for your time and expertise! Rob

 

[Larra]

Diana is probably for this question than I am, but just off the top of my head it would seem to me that if your wife's policy covers bariatric surgery for someone who medically qualifies (which she does), then she's covered. Just make sure they include the VSg, since that's what she wants. Many policies do these days, but a few still don't. And of course she'll have to go through the usual rigamarole of consults, tests, pre-op months of doctor supervised weight loss attempts, i.e. whatever your/her policy demands.
But it certainly would be cheaper for her to have coverage for bariatric surgery at least for the next year, and if either of you want to change your insurance at next year's open enrollment period, after her surgery, you can do so.

 

[robs477]

Diana is probably for this question than I am, but just off the top of my head it would seem to me that if your wife's policy covers bariatric surgery for someone who medically qualifies (which she does), then she's covered. Just make sure they include the VSg, since that's what she wants. Many policies do these days, but a few still don't. And of course she'll have to go through the usual rigamarole of consults, tests, pre-op months of doctor supervised weight loss attempts, i.e. whatever your/her policy demands.
But it certainly would be cheaper for her to have coverage for bariatric surgery at least for the next year, and if either of you want to change your insurance at next year's open enrollment period, after her surgery, you can do so.

Larra, Thxs for the reply and the info, but, to clarify, my Wife's Ins company does not cover Bariatric surgery of any kind even if medically necessary.

 

[Larra]

I got that! What I'm saying is that she could switch to your policy now, during open enrollment, get her surgery done next year, and then, if she wants, switch back to her company's insurance. Once it's done, it's done, and they can't refuse to cover her just because she has had the surgery. So to my mind, the only issue is to make sure that the procedure she wants is covered under YOUR policy, then once her coverage starts she need to move right along to jump through all the hoops to get her surgery done before next year's open enrollment period so that she can change back to her company's insurance if she wants.

 

[robs477]

@ Larra, yes, that is what the plan is, and the VSG is covered on my plan. I was just concerned about the Insurance company having two WLS in one year on my plan, two different people, but still, they probably wont be happy? and expect they should look for a reason to get out the second one, hers. Might just be over paranoid....lol

 

[Larra]

I agree they may not be happy about it, but if she's covered, she's covered. I still hope Diana will chime in, as she understands policies better than I do.

 

[DianaCox]

My concern would not be about getting her VSG under your policy, but rather if she switches back to HER policy in 2016 and thereafter, is she going to be able to get follow up care for a surgery her company's policy doesn't cover? You need to look at that in HER policy before she switches back.

 

[Larra]

Diana makes a valid point, but with a VSG how much follow-up does she need? She won't malabsorb, no adjustments needed (like with lap band), her surgeon should provide her with a post-op diet, etc. She may need some annual labs, but I would hope her pcp would order those for her. If not, she needs a new pcp.

 

[DianaCox]

Labs and any complications she might have from the sleeve - a stricture, reflux, a leak.

 

[Spiky Bugger]

@ Larra, yes, that is what the plan is, and the VSG is covered on my plan. I was just concerned about the Insurance company having two WLS in one year on my plan, two different people, but still, they probably wont be happy? and expect they should look for a reason to get out the second one, hers. Might just be over paranoid....lol

I know nothing, but...I cannot imagine denying surgery to one family member because another family member had that surgery this year. (OTOH, you are in Texas and I can't imagine half of what happens there! Lol)

You will be paying separately for her, so her coverage is her coverage.

Even if you have to carry her on your policy for two years, it will be cheaper than paying out of pocket.

 

[Spiky Bugger]

Labs and any complications she might have from the sleeve - a stricture, reflux, a leak.

Idle curiosity question...if any of those things present while she is on Rob's policy, then they would be pre-existing and Aetna could not refuse to cover them, right?

 

[Charris]

When I had Rny in 2000 I had Cigna. My x husband and i both had surgery within 3 months of each other. We both got approved for abdominalplasty, legs, arms, and chest. We both chickened out on legs,and arms. He had his chest done and I chickened out. We both had abdominalplasty. Also keeping in mind all plastics and wls were not to be paid for at all. CIGNA WAS so good to me. I was never denied for anything. They even paid for my revision to DS. As of july 1 2014. I have united health care I hope that they will be half as good.

Good luck

 

[DianaCox]

Idle curiosity question...if any of those things present while she is on Rob's policy, then they would be pre-existing and Aetna could not refuse to cover them, right?

I'm not sure how that works with ACA - insurance companies can still exclude coverage of ANY obesity treatments, so I can envision that that exclusion could include complications resulting from uncovered procedures. If someone got a facelift, and the scar opened up, or got a breast implant which ruptured, I can see insurance refusing to cover those things.

 

[Spiky Bugger]

I'm not sure how that works with ACA - insurance companies can still exclude coverage of ANY obesity treatments, so I can envision that that exclusion could include complications resulting from uncovered procedures. If someone got a facelift, and the scar opened up, or got a breast implant which ruptured, I can see insurance refusing to cover those things.

I get that, but...if the complication presents under the first policy...the one that covered the procedure...then additional treatment of that complication might have to be covered because the complication is not wls...since I like to argue.

 

[DianaCox]

Nope. As far as I know, it is still possible to exclude not only certain procedures, but also consequential conditions. But I can't point to a particular plan that has those restrictions. Maybe Rob can get a copy of his wife's current Evidence of Coverage, in particular the exclusions?