Insurance & Fees

Medical Insurance carriers were required to cover Obesity as a diagnosis as of 2010 as an essential benefit of the Affordable Care Act. However, how this benefit is included in plans varies greatly by insurer and because of this we can never guarantee coverage by any carrier. Island Health Weight & Wellness will do our absolute best to quote you what your insurance may cover based on the coverage other patients have received. Once your office visit or testing claim is submitted we are legally required to follow its Explanation of Benefits (EOB) regardless of what was quoted or told to us when we call to verify coverage. Therefore, we always recommend you contact your carrier prior to starting the program and make sure you have Obesity coverage as a benefit. You will be held responsible for any costs that your insurance carrier does not cover.

Important: If you are over 65, other variables become relevant to your coverage. If you are still working or did not sign up for Part B of Medicare, you are more likely to have coverage at IHWW.

DO Provide Coverage

HMSA PPO / FED – Congratulations! You have one of the best plans for coverage at IHWW! If you have a yearly deductible, you will have to pay that out of pocket first, but then you will only pay your regular doctor’s office copay and tax for your appointments. You will have a small copay on your EKG ($6-7) and body composition test ($28) but other than that, your costs will be paid for by HMSA. HMSA FED plan even covers your tax.

HMSA HMO – Great news! A long as your Primary Care Provider (PCP) is willing to sign our referral form, you will have excellent coverage at IHWW. If you have a yearly deductible, you will have to pay that out of pocket first, but then you will only pay your regular doctor’s office copay. You will have a small copay on your EKG ($6-7) and body composition test ($28) but other than that, your costs will be paid for by HMSA. When you complete your FREE consultation at IHWW, make sure to leave with a referral form for your PCP to sign.

HMSA AKAMAI ADVANTAGE – Good news! You most likely are covered as long as this is your primary insurance and not Medicare. If Medicare is primary, you may not have coverage unless you did not sign up for Part B. These plans have covered for most but not all patients over the age of 65. If you have a yearly deductible, you will have to pay that out of pocket first, but then you will only pay your regular doctor’s office copay. You will have a small copay on your EKG and body composition test ($28) but other than that, your costs will most likely be paid for by HMSA.

BLUE CROSS BLUE SHIELD – Good news! In Hawaii BCBS goes through HMSA and HMSA offers great coverage at Island Health. If your BCBS insurance is through your employer on the mainland, however, this could alter your coverage from being in network to out of network, so while we can’t guarantee they will cover, they have for almost every other patient thus far. If you have a yearly deductible, you will have to pay that out of pocket first, but then you will only pay your regular doctor’s office copay. You will have a small copay on your EKG and body composition test ($28) but other than that, your costs will most likely be paid for by BCBS.

AETNA, CIGNA, UHC (United Healthcare) – Good news! These insurers have offered great coverage at Island Health. If your Aetna, Cigna or UHC insurance is through your employer on the mainland this could alter your regular coverage rates from being in network to out of network so while we can’t guarantee they will cover, they have for almost every other patient thus far. If you have a yearly deductible, you will have to pay that out of pocket first, but then you will only pay your regular doctor’s office copay. You will have a small copay on your EKG and body composition test ($28) but other than that your costs will most likely be paid for by Aetna, Cigna, or UHC.

HMA – Good news! We are in network with HMA and they have covered very well for many patients. Most patients have a 10% copay of the office visit charges which is $10-15 as well as tax. If you have a yearly deductible, you will have to pay that out of pocket first. You will have a small copay on your EKG and body composition test ($28) but other than that your costs will most likely be paid for by HMA. HMA did alter their third party administrator in 2016 which was disruptive to some patient’s coverage, but they were all still covered. Some just experience out of network costs (20% copays instead of 10%).

HMAA – Good news! HMAA has covered for many of our patients. They state that they only offer coverage for patients with a BMI of 40 or greater but they have covered many IHWW patients with lower BMIs as well. We believe they see the value in helping their members lose weight. Because their written rules are different then what they have covered for us, we cannot guarantee coverage for any HMAA members but all of the patients in 2016 received excellent coverage. If you have a yearly deductible, you will have to pay that out of pocket first. You will have a small copay on your EKG and body composition test ($28) but other than that your costs will most likely be paid for by HMAA.

KAISER ADDED CHOICE – If you have regular Kaiser plan, they do not cover IHWW. But if you have the Added Choice option, we have successfully billed for two patients who received excellent coverage. AC members had approximately a $22 copay, small testing copay, $28 body composition test, and all other costs were paid for by Kaiser Added Choice.

TRICARE STANDARD – Good news! Tricare Standard allows IHWW to do your referral for you so when you come in for your FREE consultation and decide you want to get started, we will fax them your referral to get you coverage. As of 2016 all Standard members had excellent coverage typically with no deductible or copay, although some members did have a small deductible ($100-300) and copay ($12). Tricare covered all testing costs excluding the body composition test ($28). We never guarantee anything with any Tricare plan however because in the spring of 2016 they changed their referral system without warning and many of our patients lost coverage overnight.

TRICARE PRIME / FOR LIFE – Our most challenging insurer currently. If you can get your PCM to write you a referral that is your best bet to get coverage at IHWW. The hard part is even some of the PCMs do not know how to refer to us and we are unable to aid them with this process. Even with a referral, we cannot guarantee coverage. We have seen some patients receive great coverage and others receive none. With the referral, most Tricare Prime patients do not have a deductible or copay and all testing except the body composition test ($28) is also covered. We hope to be able to update this with better information in 2017.

DON'T Provide Coverage

MEDICARE – We are not a Medicare provider and they will not accept claims from us. All patients over the age of 65 are required to sign an Advanced Beneficiary form stating you understand we cannot bill Medicare and you cannot bill Medicare for any of IHWW’s services.

HMSA QUEST – The ACA only requires Obesity coverage for private health plans so at this time Quest does not cover this benefit. You are eligible for our discount program which is outlined under the Jump Start program which you can find here.

OHANACARE – We are not in network with this insurer at this time.

UHA – We were very disappointed to lose our contract with UHA and hope they will reconsider coverage if enough of their members request it. If you have UHA, we recommend letting your Human Resources department at your work now that coverage at Island Health is not included and something you think is important.

KAISER – Kaiser offers its own weight loss program and only covers for IHWW if you have the Added Choice plan.

ALOHACARE – We are not in network with this insurer at this time.

Patients whose insurance does not cover the medical weight loss program at IHWW can still be patients and they are eligible for our discount program!

Insurance FAQ

Q: Why doesn’t my insurance cover your services?

A: There are a number of potential reasons:

Your plan is “grandfathered out”: If your insurance plan was created before 2010, it may not include preventive services. Many insurance companies are updating grandfathered plans even though they don’t have to, because they see the benefit of offering these benefits to their subscribers. We have seen this with some HMSA plans.

IHWW is not in-network with your insurance company: We want to be! Some insurance companies such as UHA and HMAA are not willing to allow us into their network at this time. It doesn’t mean they won’t in the future if enough people request it. An insurance company can make this decision at any time and for any reason.

Obesity is not a benefit of your plan: When you chose your plan through your job, you may have chosen a plan that does not include an Obesity benefit. Call your HR at work to find out if your insurance includes preventive benefits including Obesity. According to the 2010 Patient Protection and Affordable Care Act (PPACA) also known as Obamacare, ALL private insurance companies are REQUIRED to cover Obesity as a benefit. Medicaid does not offer preventive benefits and is not mandated to by the federal government at this time.

IHWW cannot participate in your plan: Medicare, which does offer preventive benefits including obesity, has a very low reimbursement rate for this diagnosis. It is so low we would not be able to afford our operating costs even if we had a completely full clientele of Medicare patients! Therefore, we have chosen to not be a participating provider with Medicare.

Q: What can I do?

A: Write a letter to your Human Resources department at work as well as your insurance company. We have found this is by far the most effective way to promote change.