State Medicaid Coverage Of Adult Obesity Treatment
All state Medicaid programs covered at least one obesity treatment modality. Eight states covered all three treatment categories with various restrictions. Twenty-six states explicitly covered nutritional consultation, while 20 explicitly did not. Drug therapy was the least frequently covered and discussed treatment category only 10 states covered it, while 33 states made no mention of it in their provider manuals. Bariatric surgery was the most frequently covered treatment it was also the least likely to be explicitly not covered . Three states explicitly excluded nutritional assessment/counseling and drug therapy, while covering bariatric surgery .
Is Bariatric Surgery Covered By Insurance
Most commercial insurance plans approve all four typical weight loss surgical procedures gastric bypass, vertical sleeve gastrectomy, gastric banding with LAP-BAND® or REALIZE® bands, or duodenal switch procedures for the appropriate patients.
To receive approval, a patient usually needs to have a BMI above 40, or a BMI between 35 and 39 if the patient also has certain medical conditions such as diabetes, sleep apnea, or high blood pressure. Some insurance companies have a mandatory three-month weight management protocol that you must complete before surgery. Some have a protocol as long as six months.
For all plans, dietary and psychological evaluations are mandatory. This is a practical step that helps ensure your readiness for the procedure.
Your medical team can work with you to help you meet the particular requirements of your health plan in order to qualify for insurance coverage.
How Does Medicare Cover Bariatric Weight Loss Surgery
How Medicare covers weight loss surgery depends on the type of surgery you get, particularly whether you’re an inpatient or outpatient. So, we first need to understand the parts of Medicare.
- Medicare Part A is also known as hospital insurance, because it covers inpatient care received in a hospital or skilled nursing facility .
- Medicare Part B is also known as medical insurance, because it covers outpatient services like doctor visits, lab work, mental health care, and durable medical equipment .
- Medicare Part C is more commonly known as Medicare Advantage. These are health insurance plans provided by private insurance companies working under guidelines set by the Centers for Medicare & Medicaid Services . When you join a Medicare Advantage plan, you get your Parts A and B benefits in one policy. In addition, most Advantage plans also provide extra benefits, like prescription drugs and routine vision and dental care.
- Medicare Part D provides prescription drug coverage. As with Part C, private insurance companies sell Part D prescription drug plans. You may get these benefits through a Medicare Advantage Prescription Drug plan or by joining a standalone Medicare Part D plan.
Original Medicare includes Parts A and B. You may also join a Medicare Supplement Insurance plan, more commonly known as Medigap. These plans help pay some of your out-of-pocket costs when you have Original Medicare. You cannot have both a Medicare Advantage plan and Medigap.
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Do Other Medicare Supplement Plans Cover Weight Loss Programs
Medicare supplement plans, also known as Medigap or MedSupp, are policies that fill in the gaps of Original Medicare, providing a more comprehensive health care plan. Like MA plans, Medigap plans may help cover the costs for weight management services and fitness programs. Medicare beneficiaries should contact their insurance company to learn more.
Government Aid For Weight Loss Surgery Costs
The federal government can help pay for procedures for qualified patients under the Medicaid and Medicare programs. Both programs have eligibility restrictions, in addition to an application process and waiting period.
- Medicaid provides health insurance to low-income individuals, and will cover gastric bypass surgery in certain extreme cases. Many requirements must be met in order for Medicaid to cover weight loss programs and surgery, including medical proof that you meet certain weight qualifications and have tried other methods to lose weight.
- Medicare covers bariatric surgery for individuals who meet specific criteria related to morbid obesity. You will still have to meet your deductibles before Medicare will pay, and you may be responsible for copays for follow-up visits after your procedure.
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What Is Biliopancreatic Diversion With Duodenal Switch
Biliopancreatic diversion with duodenal switch is similar to gastric bypass, in that it creates a smaller stomach and bypasses most of the small intestine. However, instead of creating a small, pouch-like stomach, BPD/DS uses sleeve gastrectomy to remove 80 percent of the stomach. The gastric sleeve leaves a tube-shaped stomach that resembles a banana. The patient gets the same benefits feeling full more quickly thanks to a smaller stomach and malabsorption of calories. Unfortunately, this also leads to the same nutrition deficiencies seen in gastric bypass. The procedure is extremely effective, although it has more risks than either gastric bypass or LAP-BAND. Typically, your doctor will only recommend BPD/DS if your body mass index is over 50.
Types Of Bariatric Surgeries
Bariatric surgeries change the structure of the digestive system to limit food consumption by the patient. The four most common types of bariatric surgery include:
Gastric bypass surgery, which creates a new stomach and bypasses a small portion of the small intestine
Gastric banding, which uses an adjustable gastric band around the upper portion of stomach
Gastric sleeve surgery removes 85% of the stomach and
Biliopancreatic diversion removes 70% of the stomach.
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Ways To Get Help Paying For Bariatric Surgery
While bariatric surgery costs can be higheven with insurancehundreds of thousands of people find ways to cover costs every year. When you consider how feeling healthy can impact your lifestyle and future, the surgery often ends up paying for itself. Dont let costs stand between you and a healthy future. Here are three free resources you can use to get help paying for bariatric surgery:
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Sleeve Gastrectomy With Single Anastomosis Duodeno
Zaveri et al noted that the increase in the prevalence of obesity and gastro-esophageal reflux disease has paralleled one another. Laparoscopic fundoplication is a minimally invasive form of anti-reflux surgery. The duodenal switch is a highly effective weight loss surgery with a proven record of long-term weight loss success. However, fundoplication alone does not give satisfactory results when used for GERD in morbidly obese patients. These researchers presented a novel approach combining stomach intestinal pylorus sparing surgery with LF for morbidly obese patients with GERD. The data from patients who underwent the SIPS procedure along with LF in past year was retrospectively analyzed. The variables collected were age, sex, height, weight, intra-operative and post-operative complications, length of stay, operative time, and estimated blood loss. All revisions were excluded. Descriptive statistics such as mean and standard deviation were used to analyze the data. The total sample size of the study was 5 patients, with a mean age of 59.6 ± 16.4 years, a mean weight of 292.1 ± 73.6 lbs., and a mean body mass index of 43.4 ± 6.3. Weight loss patterns were the same as those without LF. All 5 patients had resolution or improvement in their GERD symptoms within 6 months. The authors concluded that SIPS with LF provided substantial and sustained weight loss and GERD resolution. however, long-term follow-ups and further study on this novel surgical technique is recommended.
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Lets Take A Closer Look At The Different Types Of Bariatric Surgery
Some of the common types of Medicare bariatric surgeries include gastric bypass, lap band surgery and gastric sleeve surgery.
Gastric bypass surgery
This common malabsorptive weight loss surgery is also known as Roux-en-Y gastric bypass . In this procedure, a small stomach pouch is created to restrict food intake. The rest of the stomach is bypassed via a Y-shaped segment of the small intestine, which reduces the amount of calories and nutrients the body absorbs.
LAP-BAND® surgery
This surgery is defined as Laparoscopic adjustable gastric banding . This common weight loss procedure involves the placement of a hollow band around the upper end of the stomach, creating a small pouch and a narrow passage into the larger remainder of the stomach. The band is inflated with saline solution, which can be increased or decreased over time to alter the size of the passage.
Gastric sleeve surgery
This weight loss surgery is also commonly known as vertical sleeve gastrectomy or sleeve gastrectomy . This procedure involves the removal of the greater curvature of the stomach and approximately 80% of the stomach volume. While pyloric sphincter and stomach functions are preserved, the remaining stomach resembles a slender curved tube.
What Is Your Status
Even if Medicare will cover your bariatric surgery, how it does so can vary based on a few factors, namely, where you get the surgery. A bariatric surgery can be performed in both an inpatient and outpatient setting, which changes which part of Medicare covers your surgery. Much like with observation status, you could have your surgery at a hospital and still have it covered by Medicare Part B, since youâd be counted as an outpatient. Bariatric surgeries can also be given in other outpatient facilities like ambulatory surgery centers. Where you have the surgery depends on how much youâll owe out-of-pocket through Medicare.
Letâs go with the lower end of the typical cost range, which is $20,000. If this treatment is given as part of inpatient care, youâll owe your Medicare Part A deductible and a coinsurance for any days spent in the hospital if youâre there longer than 60 days. The Part A deductible is $1,484 in 2021 and $1,556 in 2022. Patients generally spend two to five days in the hospital recovering from a surgery, so youâre unlikely to experience a coinsurance under Original Medicare. Some Medicare Advantage plans may have a daily copay, though this differs from plan to plan.
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Does Medicare Cover Bariatric Surgery
- You can read about other patients experiences getting weight loss surgery covered by Medicare
- You can ask the expert
We would love to hear your experiences with medicare and bariatric surgery. Your insights are invaluable to making sure other people have the tools to meet their goals.
We would also be happy to answer any questions you may have about medicare and bariatric surgery.
Please use the form below to share your experience or ask a question.
Do I Qualify For Bariatric Surgery With Medicare
If you are enrolled in Medicare, the first step is to see your doctor. You will need a doctors approval and diagnosis, both to see if bariatric surgery is right for you, and to have a record for when you start discussing your options with Medicare and your bariatric surgeon.
There is no pre-approval process for Medicare bariatric surgery. Each patient is reviewed on a case by case basis. If you are interested in undergoing this type of surgery through Medicare, start with the following process:
- Find a Medicare-approved bariatric surgeon.
- Ensure that you qualify for Medicare to pay for bariatric surgery.
- Complete any and all special meetings and consultations the surgeon requires.
- Complete all of your testings, including lab work, x-rays, and more.
- Have the surgeon contact Medicare with all of the results of your medical tests.
The approval process can be lengthy. For those that are in need of immediate treatment, it may be best to see if there are other options out there. But once you have completed this process, if you meet all of their requirements, you should be able to receive bariatric surgery medical treatment.
Danielle Kunkle Roberts is the co-founder at Boomer Benefits, an agency that helps baby boomers navigate their entry into Medicare.
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How Much Is Weight Loss Surgery
Answer: Most surgeons will work with your insurance company to determine your out-of-pocket expense and will be able to provide you with your full cost. The price of your weight loss surgery will depend on several factors:
- The type of surgery youre having. Types of weight loss surgery include gastric bypass, adjustable gastric banding, sleeve gastrectomy, and duodenal switch. Each has a different fee and the procedure suggested for you will be made based on your history and the surgeons recommendation.
- Your surgeons fee. This will vary based on the procedures complexity.
- The hospital you choose. Costs will vary and may include the operating and hospital rooms, among other fees.
Does Medicare Cover Gastric Sleeve Surgery
Medicare does cover gastric sleeve surgery when available in your service area. The level of coverage also depends on whether youre getting care as an inpatient or outpatient. Gastric sleeve surgery removes and separates about 85% of the stomach, and then the remaining gets molded into a tubular shape that cant contain much food or liquid.
Patients lose an average of 65% of extra weight after gastric sleeve surgery, which may be why it was the fastest-growing bariatric surgery in 2019.
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Bariatric Weight Loss Surgery Is Available To People Who’ve Failed To Lose Weight Even With A Doctor’s Help
As with most major health insurance plans, Medicare covers bariatric weight loss surgery for qualified beneficiaries. In addition to meeting certain conditions, you will have a variety of out-of-pocket costs. On this page, we describe the three types of bariatric weight loss surgery covered by Medicare, your costs, and how to qualify.
Which Weight Loss Surgery Is Best
The study found that gastric bypass surgery boasted the greatest weight loss both short- and long-term. But that procedure also had the highest rates of complications in the month following surgery. There are trade-offs. Bypass is more effective for weight loss, but has a greater risk of short-term complications.
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Private Health Coverage For Weight Loss Surgery
Furthermore, Private Health Funds will cover the hospital fees associated with any procedure that has an Item Number, including weight loss surgery.
Private Health Funds usually offer different levels of cover depending on your monthly premium or plan.
As is common with most procedures, there is usually an out-of-pocket gap that the patient must pay as the rebates from Medicare and Private Health Funds are not sufficient to cover all the associated costs with our complete
Which Bariatric Surgeries Are Covered By Medicare
Medicare coverage includes a wide range of weight-loss surgeries. These include:
- Duodenal Switch: In this surgery, 70% of the stomach is removed instead of 85% of the stomach with gastric sleeve surgery. Duodenal Switch surgery is relatively new, which means healthcare providers are not as familiar with this procedure as they are with others.
- Lap Band Surgery: Lap band surgery involves placing a thin, adjustable ring around the upper stomach. The gastric band creates a smaller stomach, which results in feeling fuller with a much smaller amount of food.
- Gastric Bypass: Gastric bypass involves changing the way your stomach and small intestine digest food. This results in restricting the amount of food your stomach can hold, leading to fewer calories being ingested.
- Sleeve Gastrectomy: During sleeve gastrectomy, around 80% of the stomach is removed. This leaves a tube-shaped stomach that is significantly smaller, restricting the amount of food you can consume as a result. Note: this procedure is only(covered on a region by region basis. Check with your bariatric surgeon to ensure Medicare will cover this surgery.
- Lap Band Fills: Lap band fills are also covered following gastric band surgery. The doctor uses a needle to insert it into the port located on your abdominal wall with lap band fills.
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What Weight Loss Procedures Are Covered By Medicaid
When coverage applies Medicaid does cover gastric bypass, gastric sleeve surgery, and Lap-Band Surgery in most cases. These surgeries are among the most popular and are more readily accepted by Medicaid as being medically vital to a patients life in certain situations.
- Gastric bypass is a procedure that essentially bypasses a part of your intestine sending food straight to the lower intestine. This procedure also reduces the size of the stomach allowing for less food to be eaten. In bypassing a portion of the digestive process, the body will not absorb as many calories or nutrients. This will result in weight loss along with the smaller intake of food.
- Lap-Band surgery is accomplished by placing a band made of silicon and containing balloons around the top part of the stomach. This makes less space for holding food and makes the entrance for food going into the stomach smaller. The procedure is done laparoscopically and is minimally invasive compared to other surgeries. The band is adjustable and the procedure is reversible.
- Gastric sleeve surgery is the process of creating a smaller stomach that is shaped like a sleeve. This gives the food a smaller space to sit in and also directs the food downward through the intestines. This procedure reduces the amount of food that can be put into the body and is generally not considered to be reversible.
What Is Bariatric Weight Loss Surgery
Bariatric weight loss surgery makes physical changes to your digestive system to help you lose weight. In every case, the patient’s stomach is made physically smaller, ensuring you feel more full, more quickly, than you did before the procedure.
Two of the bariatric weight loss procedures covered by Medicare also divert food away from the small intestine. This reduces the number of calories you absorb from food or drink .
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