Is it true? CA law requires plastics for post WLS to be covered?

[Julie R]

I just had a (large, I mean large) ventral hernia repair on Dec. 8, I'm still recovering. Despite escaping post-DS with little extra skin, I now have a scar that looks like mini-blinds and saggy skin covers my bellybutton. I did talk to the surgeon in advance about making sure this didn't happen...but it did.

I posted in a DS forum on Facebook, mentioned my positive recovery with pre and post pics, except for the pleated skin, and someone posted the following:

[name redacted] You should go to Bariatric facts and talk to @Diana and @Larra. California requires post WLS to be covered. State law.

I did read some of the Kaiser law, but as I'm not a trained attorney or paralegal, I'm not sure what it means. I guess I'm asking for a starting point. I'm a grad student, I'd like to be able to have surgery over the summer. And if it is covered, I would like a boob lift, as well.

I have ACA (i.e., Obamacare) with MediCal in California, California Health and Wellness (a managed care plan. So far it's covered everything I've needed both post WLS and other health concerns). (My DS was through employer provided excellent PPO Insurance that I lost when my husband lost his job.). I live in northern CA.

Where do I start? My PCP? Thank you in advance for your help and guidance and support.

Merry Christmas, Happy Hannukah, Happy Holidays.

Julie

 

[Larra]

@DianaCox is really the expert on this and a strong advocate as well. It isn't a Kaiser thing, it's a statute in the state of CA. I will let her provide the details as she has the exact wording of the statute and what you would need your plastic surgeon to say to get it covered. Be advised that insurers are still refusing to cover a lot of plastics despite the statute and appeals are often necessary, and even that doesn't always work as it should.

 

[Julie R]

As I said, I just heard about this yesterday. So since I'm in a managed care plan, I'm guessing I would need to start with my PCP for a referral for plastics. Thanks very much.

 

[Julie R]

PS: I don't have Kaiser; I have Medi-Cal / California Health and Wellness managed health care. I was referring to the posted lawsuit about Kaiser. I would rather go without than have Kaiser.

 

[Munchkin]

You don't have to have Kaiser. Sometimes it's great to live in California!

 

[galaxygrrl]

You don't have to have Kaiser. Sometimes it's great to live in California!

It's awesome to live in California (Besides when you are paying your mortgage, taxes, in an earthquakes, or sitting in traffic).

 

[Julie R]

Tru dat, and why I'm outta here once I finish my Masters. Overseas is my goal.

 

[DianaCox]

You first need to get a copy of your evidence of coverage document so we can figure out whether your plan is covered by the CA law. There are exclusions under Medicare for example.

http://law.justia.com/codes/california/2011/hsc/division-2/1367-1374.195/1367.63

"(4) For services provided under the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), denial of the proposed surgery if the procedure offers only a minimal improvement in the appearance of the enrollee, as may be defined in any regulations that may be promulgated by the State Department of Health Care Services.

(f) As applied to services described in paragraph (2) of subdivision (c) only, this section shall not apply to Medi-Cal managed care plans that contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) of, Chapter 8 (commencing with Section 14200) of, or Chapter 8.75 (commencing with Section 14591) of, Part 3 of Division 9 of the Welfare and Institutions Code, where such contracts do not provide coverage for California Children s Services (CCS) or dental services."

ETA: your Medi-Cal plan may or may not be covered by this law - we need to investigate YOUR plan.

 

[galaxygrrl]

So wait, my health insurance which had an 8k limit on my WLS might pay for my plastics. how do I find this out?

 

[DianaCox]

You have to get a copy of your EoC. And you need to find out if your plan is self-funded or fully funded. And you need to find out whether your insurance plan was DELIVERED in CA if your company has offices in multiple states.

 

[galaxygrrl]

Thanks! I'll get on it.