Surgical Weight Loss Benefit Description
Sponsored by Coushatta Resort and Casino
Administered by BARInet PPO
Customer Service: 855-931-6555
a. Covered Health Plan members, Spouses and Dependents
b. Must be a Covered Health Plan member for at least 2 years
The eligible member must comply with the following requirements:
- Verification of Benefits
- Candidates for bariatric surgery must be at least 18 years of age
- The candidate must have a BMI of one of the following:
- BMI of 40 or more;
- 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.
- Evaluation by BARInet Provider
- Physical examination and verification of comorbid conditions
- Appropriate Medical referral for any identified complicating medical condition
- Medical Weight Management by a BARInet Provider for three (3) consecutive months to be done within 1 year of surgery.
- Nutritional evaluation by dietician
- Psychological evaluation by BARInet approved Psychologist
- Completion of preoperative medical workup:
- Laboratory examination
- Radiological evaluation (chest x-ray, UGI) and EKG – AS NEEDED
- Review of psychological evaluation
- Review for completion of educational and nutritional evaluations
- Preoperative visit with review of the surgical plan and postoperative requirements
- Patients is responsible for any copay or deductible that is required
- Surgery at a BARInet facility
- Post-surgical follow up as directed by BARInet Surgeon (required, to be eligible for copay reimbursement)
- Compete one (1) mandatory post-op psychological evaluation yearly following surgery
- Attend at least three (3) support group meetings within the first 6 months following surgery
- Attend follow up appointments after surgery ( 2 weeks, 2 months, 4 months, etc., and yearly thereafter)
- If program member is not actively participating in pre and post-operative program requirements, then the program member will NOT be eligible for reimbursement of program member out-of-pocket expenses (copay).
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 ONLY.
Program member will be responsible for any coinsurance after deductible and any applicable copays for office visits. Services must be performed by BARInet provider to be eligible.
The program member co-pay for the surgery benefit will be $2,500. The co-pay can be paid using Flexible Savings Account (FSA) medical dollars.
*Please note that these amounts ONLY include costs related to the surgical episode, and that all other charges will be billed to the member’s group health plan.
Surgical Out of Pocket Reimbursement
Program members may qualify for reimbursement of their initial $2,500 out of pocket co-pay when the following criteria are met:
1. 1 year post- surgery, program member must have attained 40% targeted weight loss, with an additional loss of 10% at year 2, an additional 5% at year 3, an additional 5% at year 4, and an additional 5% at year 5 surgical anniversary (a total of 65% at year 5). 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 $500 per year for a total of $2,500 after 5 years. Members must fill out a reimbursement form 1 year post surgery, 2 years post-surgery, 3 years post-surgery, and 4 years post-surgery, and 5 years post-surgery in order to receive the entire $2,500 out of pocket co-pay back.
• Weight loss will be monitored by 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. Continuation of coverage under COBRA meets this requirement.
• The reimbursement will be in the form of a check issued by the Coushatta Human Resources Department and payable to program member.
• Out of pocket expenses include the 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 medically supervised weight loss programs (coinsurance, prescription drug and office visit