I Have the Worst Insurance Plan Anyone Could Possibly Have
Now what?
Hi Everyone,
This newsletter will get into the thick of how medical insurance works on the inside. I’m going to throw out a lot of heavy insurance language, which may make your eyes glaze over. I’m here to clarify anything that doesn’t make sense, so bear with me. Please comment if you want clarification on anything, and I’ll do my best to answer your questions.
In one of my previous newsletters, I showed some PPO plans with benefit language examples of medical policies for Lipedema surgery. Insurance is starting to approve surgical benefits as Lipedema becomes more accepted. They didn’t do this on their own. This change happened because many insurance plans have lost class-action lawsuits.
However, some insurance plans still don’t have plan language for Lipedema. My insurance plan is one of them.
Regardless, you can still get your plan to approve liposuction for Lipedema even if they don’t have plan language. Don’t give up just because your insurance hasn’t written out the benefits.
But here’s the worst part for me; my insurance is self-funded. This means the company I work for is their own insurance. They provide health benefits directly to employees, and if there’s no plan language written out in the benefits, a self-funded plan can ultimately decide if they want to cover or not cover, regardless of whether or not the procedure is medically necessary.
When I had my case management company, I contracted my services with self-funded plans. These plans play by different rules because the same laws don’t govern them as fully-insured plans. Self-insurance is governed by ERISA, which is on the federal level and has more flexibility. Fully-insured plans must comply on a state level, and laws are stricter.
Where fully-insured plans give equal benefits to all employees, from the CEO to the janitor, Self-insurance may offer CEOs and upper management more extravagant coverage than their workers. They can also decide to pay medical services to CEOs that they’d otherwise not cover for their employees.
Self-insurance can also amend their plan language at any time and exclude benefits if that benefit is costing them too much. For instance, I had one case of a hemophiliac who needed Factor 8 medication, which cost upwards of $100,000 per year. This man was a regular employee of this self-funded company. The company amended its medical plan to exclude Factor 8 medication. The employee lost his benefits and ultimately quit his job.
I saw all kinds of atrocities like this for the employees I advocated for as they lost their benefits under self-insured plans. It was why I got out of working for the insurance industry and returned to working in the medical field.
Personally, my medical insurance has no plan language that specifically covers liposuction surgery for Lipedema. On top of that, if my surgery is approved by the TPA (third-party administrator who manages the self-insured plan), the CEOs of my company can decide whether or not they will cover the procedure regardless of medical necessity.
On top of that, I have no benefits if I go outside of my network for surgery. Some medical plans have out-of-network benefits, paying a lower percentage if you’re treated by a physician not in your PPO network. My insurance plan has zero coverage for physicians not contracted with my PPO.
I know I can show my insurance is medically necessary. I can show that I must use a surgeon outside my PPO network because there are no Lipedema specialty surgeons within the plan. This scenario is my career in a nutshell. However, I realize that my insurance plan may not approve my surgeries regardless of medical and out-of-network necessity.
I’m still going to work on getting my surgery approved.
I’ll keep talking about this without becoming too boring, so stick with me!
My question to you is, what type of plan do you have? Knowing the answer to this is the first step toward getting your surgery covered. Let me know in the comments below, and if you aren’t sure, also let me know.
Take care,
Michelle