Tanya
I will try to answer your questions, to the best of my knowledge. First of
all, the reason plans and Medical Necessity criteria etc seem to differ from
state to state is because each BCBS is a separate entity. However, there are
been some that have begun to merge and streamline their technologies and benefit
plans. For instance, BCBSTX merged with BCBSIL in 1998 (when I came on
board). We now share the same technology, bank accounts, name (Health Care
Service
Corporation) etc, just like a merged company. There is also the Regents
Group, which is some states merged together, more of the western states. So
even
though they share the name BCBS, each state has different plans, processes,
technology and criteria.
Another reason there may be so many conflicting situations within the same
state is because there are so many diffrent plans. The basic BCBSTX POS and PPO
plans cover WLS if it meets medical necessity criteria. The HMO plan does
not cover it (not sure why, its excluded though). However, they are doing away
with the HMO's (mine went away at the beginning of the year, but I was
changing anyways, and I think my POS plan is even better now). Most employers
can
choose to purchase one of these three plans, OR..if itis a larger plan, such as
the State of Texas Employees, Walmart etc... then they may choose to fund
their own insurance and write their own rules/exclusions etc. If this is the
case, the entity pays BCBSTX an administrative fee, and we process all of their
employees claims and the money is paid out, but it actually belongs to the
entity we administer for. We are then considered a third-party administrator.
If
this is the case, the entity gets to write their own benefits, and change as
they see fit. (ours just changed their benefits-drastically-mid plan year!
From 90/10 (network) 70/30 (out of network with 500 cyd) to 80/20 network and
60/40 out of network. And I believe they are increasing the Out of pocket in
September). They also write the exclusions to the plan (such as WLS) and they
also write up the grievance (or appeal process). Thats what I do, my title is
actually "grievance specialist" hehe. Anyways, insurance, and the medical
field in general, is very complicated.
I'm sorry this is lengthy, but I hope it helps. If you have any other
questions, please feel free to ask...I will try my best to answer :) As for
your
testing, if you are currently on COBRA, then your benefits have not changed. If
you were covered by a plan that covers WLS on the date of service, then you
will be covered. However, if you change to a different insurance (as COBRA
only lasts 18 months I believe) then any services rendered after that will be
covered according to you new insurance policies. Best of luck to you!
Chrissy