Does Medicare Cover Weight Loss Surgery?
Read PolicyScout’s guide to weight loss surgery and learn how Medicare helps with coverage.
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For many, the process of losing weight is difficult and sometimes diets, exercise, and medications can’t do the job. However, there is another alternative that overweight or obese persons can choose: weight loss surgery.
This article will teach you everything you need to know about weight loss surgery, how to get it, how much it costs, and how Medicare can help you cover it.
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What Is Medicare?
Medicare is a fee-for-service program managed by the federal government.
When you reach 65 or older, you automatically qualify for Original Medicare. Younger people with disabilities or with end-stage renal disease (ESRD) may also be eligible.
The Four Parts of Medicare
Medicare Part A (Hospital Insurance) covers inpatient hospital care, skilled nursing facility care, hospice care, and home health care.
For most, it isn’t necessary to pay a monthly premium, but when using Medicare services, a deductible and limits on coverage may apply.
Medicare Part B (Medical Insurance) is an optional coverage that requires a monthly premium. The standard amount is $135.50 (or higher depending on income,) and additional deductibles and co-pays apply. Part B covers services that Part A doesn’t, including:
Medically necessary services: Covers medically necessary outpatient care, doctors' services, and other medical services.
Preventive services: Health care to prevent illness, provide necessary cancer and diabetes screenings, and ongoing health and wellness checks.
Medicare Part C (Medicare Advantage) provides the same coverage as Original Medicare, plus additional benefits and prescription drug options.
Part C is offered through approved private insurance companies.
Medicare Part D (Prescription Drug Coverage) offers prescription drug plans through private companies approved by Medicare.
Prescription drug plans are optional and members must pay a monthly premium. Costs depend on drug coverage and convenience.
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Medicare and Weight Loss Surgery
Data from the National Health and Nutrition Examination Survey (NHANES) in 2017/2018 shows that:
Nearly 1 in 3 (30.7%) adults in America are overweight
More than 2 in 5 (42.4%) adults have obesity
About 1 in 11 (9.2%) adults have severe obesity
With this in mind, it’s important to note that Medicare covers weight loss surgery if you have met certain criteria. However, it doesn’t cover all weight loss procedures.
You will have some out-of-pocket expenses for covered services, including deductibles and co-payments. This depends on your specific circumstance and coverage plan.
The approach that you end up choosing will depend on your weight, overall health, and weight loss goals.
If you’re thinking about weight loss surgery, there are three approaches to consider:
Malabsorptive
Restrictive
A combination of malabsorptive and restrictive
Here’s an overview of each approach and what surgeries they involve:
Malabsorptive Approach
The malabsorptive approach involves surgery types that manipulate the stomach to bypass a portion of the small intestine so that the stomach cannot absorb as many nutrients.
The malabsorptive approach can:
Reduce the stomach size by two-thirds
Limit the amount of food that can be consumed and create a feeling of fullness
An example of this approach is vertical gastric banding surgery, also known as stomach stapling.
This procedure uses a band and staples to create a small stomach pouch. At the bottom of the pouch an approximate one-centimeter hole allows contents to flow into the remainder of the stomach.
The pouch limits the amount of food a patient can eat at one time and slows the passage of the food.
Restrictive Approach
With restrictive approaches, the size of the patient’s stomach is decreased so that it can’t hold as much food.
An example of this approach Is adjustable gastric banding. This is when a surgeon places an adjustable band around the stomach, reducing the stomach’s capacity to 15-30 milliliters. An adult’s stomach typically has a capacity of 1 liter.
Malabsorptive and Restrictive Approach
For weight loss surgery, both of these approaches can be combined.
Some of these procedures include:
Biliopancreatic diversion with a duodenal switch
Gastric bypass, medically known as a Roux-en-Y gastric bypass (RYGB)
Biliopancreatic diversion with a duodenal switch involves removing a portion of the stomach.
A Roux-en-Y gastric bypass reduces the stomach’s size to a small gastric pouch that typically holds around 30 milliliters.
Source: Unsplash
What is Not Covered by Medicare?
Not all treatment or surgical approaches related to weight loss are covered by Medicare.
Some of these exclusions may include:
Gastric balloon
Intestinal bypass
Liposuction
Open, adjustable gastric banding
Open or laparoscopic sleeve gastrectomy
Open or laparoscopic vertical banded gastrectomy
Supplemental fasting to treat obesity
Treatments for obesity alone, such as medical weight loss programs.
Typically, Medicare does not cover any new or experimental procedures recently introduced to weight loss programs and approaches.
Coverage is based on scientific evidence which has proved procedures or approaches safe and effective. Approved options must also be medically necessary.
If you’re not sure if Medicare will cover a weight loss procedure, contact a PolicyScout consultant at 1-888-912-2132 or Help@PolicyScout.com who will help you understand what’s covered and how much it may cost.
How Do You Qualify for Weight Loss Surgery Coverage?
In order to qualify for weight loss surgery coverage, a patient must have:
A body mass index (BMI) of 35 or greater.
BMI is a person’s weight in kilograms divided by the square of height in meters and if your BMI is 18.5-24.9, it falls within the normal or healthy weight range.
At least one comorbidity. This is a serious illness that is directly related to your obesity. For example, high blood pressure or diabetes.
Documented evidence that you have been obese for the past five years.
Documented participation in a medically-supervised weight loss program. This includes participation as well as weight loss failure in more than one program.
You must also have:
A letter from your physician suggesting or supporting that you should receive weight loss surgery.
Passed a psychological evaluation.
All treatable medical diseases or reasons for your obesity ruled out.
Adrenal, pituitary, or thyroid screening tests that return normal results.
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How Much Does Weight Loss Surgery Cost?
Many different factors can affect the cost of your weight loss surgery. These include your length of stay in the hospital, the surgical approach, and the medications needed.
Weight loss surgery typically ranges between $15,000-$25,000.
Here is a rundown of how the different parts of Medicare deal with your weight loss surgery costs.
Weight Loss Surgery and Medicare Costs
Part A will require you to pay your deductible amount before hospital coverage kicks in. In 2022, this amount is $1,556 per benefit period.
You should have no additional costs under Part A if your hospital stay is no longer than 60 days.
Part B will help cover your outpatient costs. You will also need to meet your deductible, which is $170.10 in 2022 (this is the Part B premium amount. It can increase depending on your income).
Once your deductible has been met, you are responsible for 20 percent of the Medicare-approved costs of your treatment.
Part C rates vary based on your provider and coverage, which can have their own deductibles, co-pays, and coinsurance amounts.
Medigap’s purpose is to help cover out-of-pocket expenses with Medicare coverage.
What Is Medigap?
Medigap, also known as Medicare Supplement Insurance, covers the difference between Medicare coverage and the price of premiums, deductibles, co-payments, and other costs.
It can also be used to help cover the cost of health care in other countries, which is especially beneficial to those who travel often.
However, Medigap does not cover certain other health care options such as dentistry, vision and hearing aids, home nursing, and long-term care.
Where to Find Out More about Medicare and Its Coverage Options
If you want to find out more about Medicare and how it works, head to PolicyScout’s Medicare hub to compare your options and find the best plan in your area.
We have up-to-date and accurate information about Original Medicare, Medicare Advantage Plans, or everything else related to Medicare,
If you are looking for personalized guidance, send your questions to Help@PolicyScout.com or call us on 1-888-912-2132 to get assistance from one of our experienced Medicare consultants.
Source: Unsplash