The pilot is only for members enrolled in the COVA Care and COVA Connect plans. Members seeking bariatric surgery are required to complete a 12-month education program before being considered for the surgery. This includes 12 months of weight management, nutrition counseling, disease management and personalized coaching and support services through your behavioral health benefit, and 12 months in a weight loss program such as Weight Watchers.
Why was the pre-surgery program added as a requirement for bariatric surgery?
It was added in response to a request by the 2009 General Assembly that the Commonwealth introduce a progressive weight management program instead of
eliminating the bariatric surgery benefit altogether. Its goal is to provide members with comprehensive tools to improve health outcomes and support safe, effective and long-lasting weight loss following bariatric surgery and as an alternative to surgery.
I am interested in having bariatric surgery. What do I need to do?
Contact your surgeon to initiate prior authorization for surgery. Your health plan will determine if you meet the criteria. If you do qualify for the surgery, you will need to complete the 12-month education program before surgery can be authorized.
Candidates for bariatric surgery must have a BMI of at least 40 to qualify. Can I still have the surgery if my BMI drops while going through the program?
The education program is designed to help you lose weight, reduce your BMI and prepare you for the dramatic lifestyle changes necessary for the surgery to be a success. Once you complete the 12-month program, a case manager will reassess your case to determine if your surgery will be authorized; however, the final decision about your surgery is between you and your physician.
Is there a cost to the member for this program?
There is no cost for the weight management coaching provided by ValueOptions if you are enrolled in COVA Care, or by the Optima EAP if you are enrolled in COVA Connect. If behavioral health services in addition to the EAP are needed, you will be responsible for the behavioral health benefit copayment. You are responsible for the cost of participating for 12 months in a weight loss program, such as Weight Watchers or Jenny Craig. Remember that state employees may be reimbursed for 50 percent of the cost of Weight Watchers services as long as they meet the participation requirements.
Must I be a candidate for bariatric surgery to participate in the coaching and weight management aspect of the program?
Yes, at this point the program is only open to members contemplating bariatric surgery.
Am I required to participate in the 12-month weight management coaching follow-up after surgery?
The follow-up weight management coaching is voluntary, although it is recommended to ensure long-term success. If you participate in the after-care part of the program for 12 months, you will get a refund of half of your inpatient hospital copayment. You will get a refund for the entire copayment if you participate the full 24 months.
What criteria will be used to determine whether a participant can have bariatric surgery after the 12-month pre-surgery program has been completed?
The criteria will be defined in your COVA Care or COVA Connect member handbook online. The member handbooks may be found on the DHRM Web site under each plan.
Do I have the option of deciding not to have the surgery while in the program? If I do have that option, may I continue with the program anyway?
You may decide to decline surgery at any time. If you met the criteria for bariatric surgery when you started the 12-month education program, you may complete it.
What happens if I want to have bariatric surgery and do not want to participate in the pre-surgery program?
The pre-surgery program is required before surgery can be authorized.
What if I was already scheduled for the surgery when this new requirement went into effect?
Any surgery prior authorization (PA) made before February 15 will be honored. This means that:
If you had a prior authorization on file before the program began, you will be exempt from participating in the new pre-surgery pilot.
You always have the option of enrolling in the 12 month pre-surgery program should you decide to do so.
If no prior authorization was on file before the program began on February 15, and it can be shown you were in the process of preparing for the surgery:
You will have until March 17 to obtain a prior authorization for bariatric surgery.
There must be a record of activity of preparing for surgery before February 15.
If you start the process of preparing for the surgery beginning February 15 or after, you will be required to follow the new pre-surgery program requirements.
If I have already attended one or more sessions of Weight Watchers and decide to have bariatric surgery, will I receive credit for the sessions already completed?
Members who have participated in or completed weight management programs during the previous 12 months will be given credit for their participation on a case-by-case basis.
How does the incentive program work for the voluntary weight management coaching follow-up to surgery?
The weight management coaching program is available to you for up to three years from your entry into the required 12-month pre-surgery program. You may participate on a voluntary basis up to two years following your surgery. The coaching program will track each activity during the program. Once you participate in the follow-up coaching program for one year, the plan will refund to you half of the $300 inpatient hospital or half of the $125 outpatient hospital copayment depending on what applies to your surgery. Should you continue for a second year, the plan will refund the entire inpatient or outpatient hospital copayment.
