UHC Question??

I was wondering if anyone knew what the differance is with a fully insured account. I understand that our policy has under other exclusions WLS, but the ins co said to submit a predetermination letter and there was a chance of them covering it.  Is this true or am I just getting my hopes up. 

I do not think that I am clear on your first question.  If I am thinking correctly, you are asking the difference between a fully-insured and a self-insured plan.  Fully-insured plans simply mean that the health insurance company handles most of the claims processing/payment and determinations of medical necessity in regards to any services you seek to have covered.  The health insurance company will be responsible for covering the costs of your visiting any providers.  Self-insured plans are guided by ERISA (federal laws), and the entity that provides the benefits oftentimes is the one who is responsible for payment of claims and determinations of medical necessity.  The health insurance company becomes, at that point, a third-party administrator doing all the "leg work" for the employer. Because weight-loss surgery is listed as an exclusion in your plan documents, that means that anything billed in association with weight loss will be denied payment, and you may be responsible for the charges.  However, a predetermination letter can be submitted to demonstrate medical necessity surrounding the services that you are receiving.  Ultimately, if medical necessity can be demonstrated in the letter, it can overrule what the plan documents state. Let me give you a real-life example.  I am going to have surgery on March 8, 2007 under my current medical group/insurance company, Kaiser Permanente, in South San Francisco.  Shortly thereafter, my partner will be relocating with his company to Albuquerque.  Kaiser will not be an option for us out there, so we will have to go with some form of Cigna.  Because my surgery was performed under one insurance plan, Cigna will not cover any follow-up visits required because it did not authorize the original surgery (that's part of the plan documents).  However, I can have my Kaiser doctors submit predetermination letters to Cigna, and Cigna will review the letters to determine how much coverage, if any, I can get for follow-up visits.  Without the letter, anything submitted in relation to weight-loss under Cigna will be denied.  Thus, the predetermination letter can trump the exclusion found in Cigna's plan. I hope this was of assistance to you.  You can feel free to e-mail me with any further questions if necessary.  My address is [email protected].