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 spouse’s or parent’s) employer, 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.

How your employer pays for your plan 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 SPD, 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 Exclusions

The first-step in reviewing your policy is to determine if your policy has an exclusion. Exclusions are medical services not covered by an individual’s insurance policy.

Example of Language for a Policy Exclusion:
Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, 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.

If your policy has an exclusion, you should contact your employer and encourage them to add the benefit. Often times exclusions are a tougher case to plead, however, many individuals have been successful in encouraging their employer to add a benefit. A sample letter is provided on page 11 to help when contacting your employer.

Policy Inclusions

If your policy has an inclusion, this means that your policy covers bariatric surgery, under certain specifications.

Example of Language for a Policy Inclusion:
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).

If your policy covers bariatric surgery, you will want to find out the requirements and to make sure that you meet all requirements prior to you moving forward.

Other Language to Consider

If you do not have a direct inclusion or exclusion, your policy could have some general exclusion language in one part of the plan, but specifically allow the surgery in another. Be sure to read your policy carefully to make sure you understand what is covered and what is not covered.

For instance, oftentimes policies have a section that lists “Expenses Not Covered.” While this section may seem to have exclusions, it also will provide language where there is a covered benefit.

Here is some sample language for “Expenses Not Covered:”

The medical plan does not cover the following expenses:

  • any services or supplies not specifically listed under covered expenses
  • 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,  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

Other language to consider is listed as “Covered Expenses.” This language directly lists what is a covered benefit and also provides more specifics about coverage specifics. Here is sample language for “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, liver and gallbladder disease, and cardiovascular disease. The only procedures currently allowed are Laparoscopic Adjustable Gastric Banding (LAGB) and Gastric Bypass/Gastric Bypass with Roux-en-Y.
  • medically necessary treatment or surgery to reverse procedures performed to treat obesity, weight reduction or weight control

It is important to take your time and read your policy carefully. Sometimes the wording may appear confusing or misleading. If you are having a hard time reading your policy, the best thing to do is to contact your insurance provider or benefits manager and discuss your plan in more detail.

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