When Congress designed Original Medicare back in the sixties, health insurance coverage in America was different than it is now. Our legislators broke Medicare into two parts: hospital and outpatient coverage. Medicare’s guidelines for covering almost any procedure center around whether the procedure is medically necessary.
Today in America, weight loss surgery is often considered medically necessary to combat obesity. Bariatric surgery helps to reduce the overall size of your stomach so that you feel full earlier and eat less food. Medicare offers coverage for several weight loss procedures.
Medicare will cover some or all of the following procedures: gastric bypass, lap band surgery, sleeve gastrectomy and duodenal switch. It will not, however, cover any procedure which it considers “experimental”.
Medicare Weight Loss Surgery Criteria
To help physicians determine whether a beneficiary is eligible for weight loss surgery, Medicare has criteria which a patient must meet in order to have Medicare cover bariatric surgery.
To be pre-approved for weight loss surgery under Medicare, your doctor must write a letter recommending surgery and he must certify that you meet the following criteria:
- You must have a Body Mass Index of 35 or higher
- You must have at least one comorbidity factor. This refers to a serious illness that is somehow related to your weight, such as diabetes or sleep apnea.
- Your medical records must show that you’ve been obese for a minimum of 5 years
- You’ve attempted at least one other weight loss program and failed to lose weight
- Have passed a psychological evaluation
- Other treatable diseases have been ruled out
Medicare beneficiaries must also have their weight-loss surgery performed at facilities that have been certified by the American College of Surgeons as a Level 1 Surgery Center.
Many of those that qualify for bariatric surgery will also qualify for treatment under their Medicare plan. However, this may not be true of everyone. Those with a BMI over 40 but no obesity-related medical conditions may not qualify under the above requirements. You will have to check with your doctor and Medicare to see if you meet the above qualifications.
Your Coverage and Cost Sharing Under Medicare
Medicare Part A
Medicare Part A will cover the inpatient stay related to your bariatric surgery. Whenever you have an inpatient stay, you are responsible for the Part A deductible, which is $1340 in 2018. This deductible is set each year by Medicare and usually increases a bit annually.
After this deductible, nothing more is owed for the inpatient stay unless your stay lasts longer than 60 days, which would be highly unlikely for weight loss surgery.
Part A also covers blood transfusions, home healthcare services during an inpatient stay and care at a skilled nursing facility for up to 100 days.
Most Medicare beneficiaries do not pay anything for Part A because their FICA taxes during their working years pre-pay their future Part A coverage.
Automatically enrolled if you’ve paid 10 years or more (40 calendar quarters) of social security taxes. If you’ve worked less and therefore paid less into social security, you’ll need to pay a premium. Part A covers primarily the most medically necessary hospital, skilled nursing, home health, and hospice care expenses.
Part A will typically only cover 80% of reasonable fees and will require a yearly deductible.
Medicare Part B
Medicare Part B covers outpatient services such as doctor’s visits, lab work, diagnostic tests, durable medical equipment, surgery costs, ambulance, medical supplies, mental health care and much more.
Part B will pay 80% of the cost of your outpatient expenses. You are responsible for an annual deductible ($183 in 2018), and the other 20% that Medicare does not cover. This is called your co-insurance.
Most Medicare beneficiaries pay the standard monthly premium for Part B, which is $134/month in 2018. Some beneficiaries, however, may pay more if they are in a higher income bracket. Beneficiaries who earn over $85,000 as an individual or $170,000 as a married couple will pay an Income-Related Monthly Adjustment Amount (IRMAA). This additional premium will be based on your modified, adjusted household gross income from two years ago.
Part B is not automatically enrolled, you’ll have to pay a monthly premium for this coverage. In 2016, the cost of Medicare Part B is around $104.90 each month but is dependent on your adjusted gross income. Those with higher incomes will typically pay more, from $121.80 for those making less than $170,000 (filing jointly) up to $389.90 if you make over $428,000 jointly.
Medicare Part B covers the medically necessary doctor fees, including doctor visits, preventive care, durable medical equipment, hospital outpatient services, laboratory tests, x-rays, mental health care, and some home health and ambulance services.
Medicare Part C
Medicare Part C is part of the Medicare Policy that allows third-party healthcare companies to provide Medicare Benefits. This allows users to have access to HMOs and PPOs, which is called Medicare Advantage Plans.
Medicare Part D
Medicare Part D covers outpatient prescription drugs. So, for example, if you were prescribed short-term pain medication after a Medicare-covered weight loss surgery, you would fill that medication at your local pharmacy using your Part D drug card. This gives you access to medications at a much lower cost than retail rates. You are responsible for a copay when you pick up the medications.
Part D is the portion that covers prescription drug insurance. Prescription drug coverage can only be provided through third-party insurance companies. If you have the original Medicare, which is provided via the government, then you’ll have to choose a stand-alone Part D Plan (PDP).
Each state has a dozen or more Part D drug plans to choose from, and you can find plan options available in your state by using the Medicare Plan Finder Tool.
Medicare Qualification of Weight Loss Surgery
To be qualified for weight loss surgery, this will typically mean that you must ‘medically necessary‘ for weight loss surgery.
You’ll also be required to have Medicare Part A and Medicare Part B to pay for the doctor’s evaluations and the hospital fees. Also, depending on the postoperative medications – you may need to purchase the drug coverage.
Does Medicare Cover Weight Loss Surgery?
Although Medicare will not cover 100% of any treatment, Medicare is able to cover some or all of your bariatric surgery provided you qualify. It will only cover medically surgeries that are considered to be medically sound, including:
Any surgical procedure other than those listed above is considered “experimental,” which means that it will not be covered by Medicare. This includes the Gastric Balloon Procedure, which is an effective weight loss tool but still in the early stages of research within the United States.
In addition, Medicare can help pay for some of the additional needs of patients that are undergoing this type of procedure, including the initial consultations, inpatient stay at a hotel, nutritional counseling, exercise counseling, and follow up visits.
Covering the Gaps
Since Medicare beneficiaries are responsible for the deductibles and coinsurance related to Parts A and B, most individuals enroll in additional coverage to help cover these costs. Medicare Supplement plans are offered by a variety of insurance companies, and these will especially help to pay for the 20% coinsurance that you would owe for your Medicare weight loss surgery.
Medicare has standardized Medicare supplements; there are 10 plan options in most states. This makes it easy to compare plans between insurance companies. The most popular Medicare supplements are very comprehensive.
For example, Medicare Supplement Plan G covers all of your cost-sharing except for the Part B deductible. This means that between Part B and your Medigap plan, many of your costs would be covered 100%.
Options Outside of Medicare for Weight Loss Surgery
Medicare’s criteria for weight loss surgery may prevent some individuals from being covered. Likewise, some individuals may want cosmetic surgery following their weight loss to get rid of loose skin, and this surgery is not covered by Medicare.
Medical tourism provides a great option for this at a fraction of the price you might pay in the United States or Canada. Mexico Bariatric Center employs board-certified bariatric surgeons who are well-qualified to perform these surgeries, and patients enjoy quick scheduling for surgery as well. Support is provided both before and after surgery, and risks of complications are low.
Bariatric Surgery and Medicare – Costs and Options
In addition to matching the above requirements, you will want to find a surgeon that accepts Medicare. Make sure you search for a surgeon that specializes in the types of surgery that you prefer, such as a gastric sleeve Medicare surgeon or a gastric bypass Medicare surgeon.
Medicare does not cover 100% of the surgery. You’re out of pocket medical expenses depend on the surgery and the price, but in most cases you will be expected to pay roughly 20% of the costs of bariatric surgery, while Medicare covers the remaining 80%. Costs in the United States for bariatric surgery range from between $10,000 to $40,000, making your out of pocket costs for the surgery alone somewhere between $2,000 and $8,000.
Some of these fees may be covered by MediGap, if you are enrolled in Medicare’s supplemental insurance plan.
You will also be expected to cover 20% of additional costs, such as an inpatient hospital stay. Some components of surgery and recovery may also not be covered by Medicare. Be sure and talk about each and every cost of your surgery with your surgeon before electing for the procedure, and make sure that you understand which costs you will be responsible for, why, and whether or not they are crucial for your service.
*Note: Post-Weight Loss Plastic Surgery Not Generally Covered by Medicare
It is also important to note that Medicare currently does not cover any body lifts or skin and tissue removal procedures unless there is a clear indication that your health is in jeopardy. These are considered cosmetic procedures and optional for weight loss patients. Often patients that cannot afford body lifts turn to medical tourism, which offers the same results for a more affordable price.
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 doctor’s 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 the 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.