Question:
How is it that BCBSTX (self funded plan for state employees) can deny coverage
for this surgery when Medicaid (taxpayer funded) will? Please don't take offense to this message if you were lucky enough to get this covered via Medicaid (I'm glad for ya':) )...however, I find it perplexing to understand how I as a taxpayer am responsible for paying for the cost of the surgery via income tax, and I can't even get that same kind of treatment from a state funded health insurance plan due to their written exclusion. Believe it or not, I've written my US congress folks and the President (hey...at this point in the game, anybody is worth 37 cents if they'll listen :)about this, but I still can't help but feel that this will just get pushed to the farthest backburner. How can something be considered "medically necessary" in so many other states in this country be contractually excluded in so many other plans? ??? I'm at a complete loss here. Does anybody know of any house/senate bill addressing this issue? I've tried searching the web, but I haven't been able to find the exact bill numbers...or maybe it's not even an issue for congress...I just don't know and would appreciate ANY help anyone would be kind enough to offer. — Lynda L. (posted on June 28, 2002)
June 28, 2002
Unfortunatly since you are on a self-funded plan your employer has the
right to exclude whatever they want. I don't think there are any bills in
congress right now on it but even if they pass a state mandate saying that
WLS is covered your employer being self-funded does not have to follow
them. You may try talking to someone in your HR department as on
self-funded groups they can usually make exceptions to their benefits as
well. Hope this helps.
— Heather ..
June 28, 2002
I am going through the same thing!!!! I will let you know If I find a loop
hole. Please do the same for me!
— Jenn J.
June 28, 2002
Because the person in charge of insurance for the state can exclude
whatever they want...BCBS of Texas is just the administrator of the
plan...they only do what the state tells them. You may have somekind of
appeal process through your employor...call the person who handles the
insurance and ask. I have seen (I work for an insurance company) where
self funded groups come back and ask us to override the denial and pay.
— Sharon H.
June 28, 2002
I did medical review for a hugh medical review company (who shall be
nameless here) and know that self insured companies pick and choose the
plan and exclusions they want.Because they have a "fund" that
covers everyone they are very careful so that doesn't run out. However, I
have seen the squeaky wheel get approved from everything to a tummy tuck on
a small 100 pound women who has a little skin to a tatoo being removed all
for cosmetic reasons. It's because some companies don't like to fight, risk
legal action or aren't willing to upset their employees. I know one girl
who worked for the state and it had an excusion for wls, she got Walter
Lindstrom to write the appeal letter and they not only approved her
surgery, they threw out the exclusion for the whole company. You sound VERY
intelligent and ambitious, just the kind of person to get something changed
for you and your company. Best of luck!
— ZZ S.
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