Surgical Weight Loss Benefit Description
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Administered by BARInet PPO
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a. Covered Health Plan members, Spouses and Dependents
b. Must be a Covered Health Plan member for at least 1 year
The eligible member must comply with the following requirements:
1. Verification of Benefits
2. Candidates for bariatric surgery must be at least 18 years of age
3. The candidate must have a BMI of one of the following:
a. BMI of 40 or more;
b. BMI of 35 or greater with at least one (1) accompanying weight-related comorbid conditions including but not limited to diabetes, hypertension, hyperlipidemia, sleep apnea with CPAP/BIPAP, etc. and may be determined by the Plan.
c. BMI of 30 or greater with the presence of Type ll Diabetes – to be appropriately documented.
4. Evaluation by BARInet Provider
• Physical examination and verification of comorbid conditions
• Appropriate Medical referral for any identified complicating medical condition
5. Medical Weight Management by a BARInet Provider for three (3) consecutive months to be done within 1 year of surgery.
6. Nutritional evaluation by dietician
7. Psychological evaluation
8. Completion of preoperative medical workup:
• Laboratory examination
• As needed – Radiological evaluation (chest x-ray, UGI) and/or EKG
• Review of psychological evaluation
• Review for completion of educational and nutritional evaluations
9. Preoperative visit with review of the surgical plan and postoperative requirements
• Patients is responsible for any copay or deductible that is required
10. Surgery at a BARInet facility
11. Post-surgical follow up as directed by BARInet Surgeon
12. Attend at least three (3) support group meetings within the first 6 months following surgery
13. Attend follow up appointments after surgery (Ex: 3 weeks, 6 months, 12 months, and yearly thereafter)
This program is only for primary bariatric procedures and excludes revision surgery for previous bariatric surgery procedures.
Approved surgical procedures will include the Sleeve Gastrectomy and Gastric Bypass (upon medical necessity).
Program member will be responsible for any coinsurance after deductible and any applicable copays and/or out-of-pocket costs for required pre-operative services (office visits, dietary visits, labs, imaging/testing, and psychological evaluation).
Services must be performed by or under a BARInet provider’s supervision to be eligible.
The program member will also be responsible for an additional co-pay of $2,500 for the surgery episode of surgery.
The co-pay can be paid using Flexible Savings Account (FSA) medical dollars.
Post-Operative Incentive Program
Program members may qualify for reimbursement of their $2,500 surgery co-pay amount when the following criteria are met:
• 1 year post-surgery, program member must have attained 50% targeted weight loss, with an additional loss of 10% at year 2 (a total of 60% EBWL (excess body weight loss) at year 2). Weight loss target to be determined by BARInet
provider and agreed upon by program member prior to surgery.
• Reimbursement will be distributed back to the member at $1,250 per year for a total of $2,500 after 2 years.
Members must fill out a reimbursement form 1 year and 2 years post-surgery in order to receive the reimbursement.
• Weight loss will be monitored by the BARInet provider and will be reported to the Health Plan for consideration of reimbursement.
• Program member must maintain continuous Health Plan enrollment to be eligible to receive the reimbursement.
• The reimbursement will be in the form of a check issued by the Human Resources Department and payable to program member.
• Eligible out of pocket expenses include the initial surgery co-pay of $2,500.
• Reimbursement request forms are to be completed by both BARInet provider and the program member attesting to adherence to program requirements. Forms are available from BARInet provider.
*Out of pocket expenses related to the pre-operative medical work up (labs, imaging, coinsurance, prescription drug and office visit co-pays) are not eligible for reimbursement.