For many, weight loss surgery is a necessary, urgent health procedure. Severe obesity can contribute to numerous health challenges, from diabetes to coronary artery disease, and more. Bariatric surgery is often the last resort, capable of providing rapid excess weight loss and improving your overall lifespan.
But before you can receive bariatric surgery, you have to find a way to pay for it. For many that means using their Medicare services and finding out if it is covered.
Medicare Part A, B, C, & D Overview
Part A – Hospital 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. 2016 Part A Deductible: $1,288.
Part B – Doctor Coverage: 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.
Part C – Medicare Advantage: 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.
Part D – Drug Coverage: 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).
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.
Medicare Bariatric Surgery Requirements
It should be noted that some individuals that qualify for bariatric surgery may not qualify for Medicare. Requirements are as follows:
- BMI Over 35
- One Obesity Related Medical Condition
- At Least 5 Years of Obesity Challenges
- Proven Failure at Other Forms of Weight Loss
- Complete a Psychological Evaluation
- Doctor Recommends Bariatric Surgery
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.
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. Your 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 You 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 testing, 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.