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.
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.
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 healthcare 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.
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.
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.
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.
Danielle Kunkle Roberts is the co-founder at Boomer Benefits, an agency that helps baby boomers navigate their entry into Medicare.