A growing number of Medicare beneficiaries are choosing weight loss surgery. Medicare will pay for some types of weight loss surgery if you meet certain eligibility criteria.
This article explains the details of Medicare coverage for weight loss surgery and the remaining costs you should know about.
Medicare coverage for weight loss surgery
Medicare coverage is divided into different parts, with each one covering different services. Hereâ€™s an overview of what each part of Medicare covers when it comes to weight loss surgery.
Medicare Part A
Part A covers hospital-related costs when youâ€™re admitted as an inpatient. In addition to the surgery itself, Part A will cover your room, meals, and medications during your stay.
Medicare Part B
Part B covers medical costs, such as doctorâ€™s visits before surgery, obesity screenings, nutrition therapy, and lab work before surgery. Part B may also pay for surgeonâ€™s fees as well as facility costs if you have the procedure in an outpatient (non-hospital) facility.
Medicare Part C
Medicare Part C, also known as Medicare Advantage, is required to provide at least the same amount of coverage as Medicare parts A and B. Plans may also include additional coverage to help with recovery after surgery, such as Silver Sneakers programs, healthy food delivery, and some prescription drug coverage.
Medicare Part D
Medicare Part D is the prescription drug coverage portion of Medicare. It should cover any necessary medications youâ€™d need after surgery, such as pain or anti- nausea medications.
Medigap plans cover out-of-pocket costs that Medicare doesnâ€™t cover. Your Medigap policy may help cover deductibles, copayments and coinsurance costs, depending on your policy. You can purchase a Medigap policy through a private health insurance company.
Often, your surgeon will have a coordinator discuss your financial options related to weight loss surgery. However, itâ€™s also important to contact Medicare, or your Part C provider, to ensure there arenâ€™t additional costs (like facility fees and anesthesia costs) related to your procedure.
What types of weight loss surgery are covered?
When it comes to weight loss surgery, there are three general approaches: malabsorptive, restrictive, and a combination of malabsorptive and restrictive. The best approach for you depends on your weight, overall health, and weight loss goals.
Hereâ€™s an overview of each approach:
This approach involves manipulating the stomach so it cannot absorb as many nutrients. One example of this approach is vertical gastric banding.
Vertical gastric banding involves stapling the upper portion of the stomach to restrict its size. The procedure is rarely performed.
With restrictive approaches, the size of the stomach is reduced so that it canâ€™t hold as much food. An example of this approach is called adjustable gastric banding.
In adjustable gastric banding, a band is placed around the stomach, reducing its capacity to 15 to 30 milliliters (mL). An adult stomach can usually hold about 1 liter (L).
Malabsorptive + restrictive approach
Some procedures are both malabsorptive and restrictive. These include biliopancreatic diversion with duodenal switch and roux-en-Y gastric bypass.
Biliopancreatic diversion with duodenal switch involves removing a portion of the stomach.
Roux-en-Y gastric bypass reduces the stomachâ€™s size to a small, gastric pouch that is usually about 30 mL in size.
What isnâ€™t covered by Medicare?
Medicare doesnâ€™t cover some treatment and surgical approaches related to weight loss. Treatments that may not be covered include:
- gastric balloon
- intestinal bypass
- open, adjustable gastric banding
- open or laparoscopic sleeve gastrectomy
- open or laparoscopic vertical banded gastrectomy
- supplemented fasting to treat obesity
- treatments for obesity alone (such as medical weight loss programs)
Medicare also doesnâ€™t usually cover new or experimental procedures. Coverage decisions are based on rigorous scientific data, which must prove that any new procedures are safe and effective, as well as medically necessary for its beneficiaries.
If youâ€™re not sure if Medicare will cover a weight loss procedure, contact Medicare directly (800-MEDICARE) or your plan provider to determine if itâ€™s covered and how much it will cost.
How do I qualify for coverage?
Medicare will cover weight loss surgeries if your doctor recommends the procedure based on medical necessity. There are certain criteria that you need to meet to prove the procedure is medically necessary, such as:
- a body mass index (BMI) that is at least 35 or higher
- at least one other condition related to obesity, such as diabetes, high blood pressure, or hyperlipidemia
- previous unsuccessful attempts to lose weight with medically supervised treatments (such as weight loss programs with nutritional counseling)
Your doctor may also have additional requirements for surgery. Because weight loss surgery is a life-changing process, you may be required to participate in counseling sessions and/or psychiatric evaluations.
Medicare considers each situation separately when approving bariatric surgery coverage. Your doctor must submit documentation proving youâ€™ve met Medicareâ€™s requirements for undergoing weight loss surgery. Sometimes, the process can take up to a few months before you receive approval for coverage.
How much does weight loss surgery cost?
The average cost of weight loss surgery ranges from $15,000 to $25,000. Many different factors can affect this cost, including the length of your hospital stay, the surgical approach, and medications needed.
Hereâ€™s a rundown of associated costs with each part of Medicare:
- Part A. Youâ€™ll need to pay your deductible amount before hospital coverage kicks in. For 2020, this amount is $1,408. As long as your hospital stay is no longer than 60 days, you should have no additional costs under Part A.
- Part B. With Part B coverage for outpatient costs, youâ€™ll also need to meet your deductible, which is $198 in 2020. Once youâ€™ve met your deductible, you are responsible for 20 percent of the Medicare-approved costs of your treatment. Part B also charges a monthly premium of $144.60.
- Part C. Rates for Part C plans vary based on your provider and coverage, but they can have their own deductibles, copays, and coinsurance amounts. Contact your plan or check the summary of benefits and coverage through your insurance providerâ€™s website.
- Medigap. The purpose of these plans is to help cover out-of-pocket expenses with Medicare coverage. Rates on these plans vary from company to company. You can compare and shop for plans through Medicareâ€™s website.
Consider these steps to get the maximum amount of coverage from your plan:
- If you have Medicare Advantage, check with your plan to ensure your doctors and facility are considered in-network.
- If you have original Medicare, make sure your providers are enrolled in Medicare. You can search for participating providers with a tool on Medicareâ€™s website.
Additional benefits of weight loss surgery
If weight loss surgery is deemed necessary, it can provide many different benefits to your overall health. This is one of the reasons Medicare helps cover the cost of surgery.
According to a recent journal article, weight loss surgery offers many health benefits, such as:
- reduced risk for heart disease
- improved glomerular filtration rate (a measurement of kidney function)
- improvements in respiratory function
- fewer metabolic problems, such as better blood sugar control
Medicare will cover weight loss surgery, but youâ€™re responsible for certain aspects of your care. If you have Medicare Advantage, you may need to use an in- network provider and get a referral to a bariatric surgeon to start the process.
Since the Medicare approval process involves careful review of each case, you might wait several months to get your surgery covered by Medicare. You first have to meet certain medical requirements and those of your surgeon.
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