WellnessWorks New Benefit – Bariatric Surgical Coverage
Beginning January 1, 2013 the EWTF will cover bariatric surgery in the treatment of patients diagnosed with morbid obesity. EWTF is partnering with UnitedHealthcare’s Bariatric Resource Services (BRS) who will administer this program.
How does the Program Work
A Registered Nurse (R.N.) is assigned to a patient from the time of the first call to BRS until after the surgery is performed. The nurse explains what the patient can expect during the process, answers questions, coordinates, educates and aids in the care of the patient. The patient can expect the nurse to ask about their diet, exercise and behavioral health and when the time comes the choice of surgeon and Center of Excellence (COE). BRS applies a multi-disciplinary approach to help the patient reach his/her goals.
Once the criteria is met and it’s time to choose where the patient has the procedure, the nurse will direct the patient to a Center of Excellence, a facility that is a top performing, quality bariatric center that delivers improved clinical and economic outcomes.
What is the Criteria
The EWTF Plan covers surgical treatment of morbid obesity provided all of the following are true:
- Patient is over the age of 18 and is physically mature
- Patient has a minimum Body Mass Index (BMI) of 40, or less than or equal to 35 with at least one co-morbid condition present
- Patient must use a BRS Bariatric Center of Excellence (COE)
- Patient has completed a multi-disciplinary surgical preparatory regimen, which includes a psychological evaluation
- Six (6) month physician supervised diet documented within the last 2 years (a physician supervised diet is not covered by the Plan)
- All authorization information and enrollment for bariatric surgery must be initiated through Bariatric Resource Service (BRS) Program at (888) 936-7246
What are the Benefits
- Program is effective on January 1, 2013.
- Only one (1) surgery per lifetime is payable unless medically necessary complication(s) arise.
- The maximum benefit is $100,000. This includes benefits paid at the normal liability rate once the annual deductible is met for the surgery, the psychiatric evaluation, all procedures and pre- and post-operative expenses.
- Bariatric Center of Excellence facility charges are paid at 100% of the first $7000, balance at 80% of the discounted amount per spell of illness.
- Surgeon’s charges paid at 80% of the allowed amount subject to the annual deductible.
- After the $100,000 maximum is reached, eligible expenses are covered at 50% of the allowed amount.
What is Not Covered
- Physician supervised diets including food and nutritional supplements
- Visits to nutritionists
- Excess skin removal unless medically necessary
- Revisions including any additional bariatric surgical procedures (performed primarily due to weight gain)
- Bariatric surgeries not authorized by Bariatric Resource Services
- Facilities that are not a BRS Bariatric Center of Excellence
- Refer the EWTF Summary Plan Description for a list of all exclusions.
Who do I Contact with Questions
Questions about the benefits may be directed to the Service Representatives at the Fund Office by calling (301) 731-1050 between 8 am and 4:30 pm Monday – Friday.
Questions about enrollment and/or the criteria must be directed to Bariatric Resource Services at (888) 936-7246 on or after January 1, 2013. Have your 12 digit UHC identification number handy as well as the EWTF group number 78-340001.