Will Insurance Cover Bariatric Surgery – Weight loss is a journey, and bariatric surgery is a tool used by patients seeking a healthier and often happier life. Insurance coverage is often an essential financial piece for our patients.

“Fortunately, in New York state, insurance companies are very good at providing coverage for bariatric surgery patients,” says Dr. John D. Rutkoski, a Trinity bariatric surgeon and director of Bariatric and Metabolic Surgery. of the Catholic Health system. “That’s not the case across the country, but in New York it is.”

Will Insurance Cover Bariatric Surgery

Will Insurance Cover Bariatric Surgery

Health insurance companies can provide coverage for the cost of a person’s medical and surgical expenses. However, different insurance providers may have different requirements that must be met before a patient can apply for coverage of their expenses.

How Does Bariatric Surgery Work?

Major insurance providers often have several requirements that they ask bariatric patients to complete before providing coverage for a weight loss procedure.

Trinity Bariatric Surgery has done this in the past and will continue to adjust our services to better meet the needs of our patients, as well as those of their insurance companies. We have done this by making common insurance requirements part of our pre-operative process.

Our bariatric surgery team does everything we can to help patients seeking insurance coverage for bariatric surgery. Additional support is provided by:

Updates made by insurance companies may affect the requirements a patient must meet before applying for coverage. In this case, we have seen several insurance providers make changes to their bariatric surgery requirements at the beginning of the 2020 calendar year.

Requirements For Bariatric Surgery

It has become more common for insurance companies to require that a significant weight loss attempt be made, under medical supervision, before a patient can be approved for bariatric surgery coverage. This usually consists of monthly visits to your doctor, for a period of time predetermined by insurance. It can vary from 3 months to a full year.

While our office team cannot adjust your insurance requirements, our providers remain committed to our patients every step of the way. We work hard to ensure patients feel supported, empowered and comforted in the months leading up to surgery.

To find phone numbers, addresses and hours for any of our locations, visit our locations page.

Will Insurance Cover Bariatric Surgery

If your message concerns a medical emergency, call 911 or go to the nearest emergency room. When Congress designed Original Medicare in the 1960s, health insurance coverage in the United States was different than today. Our lawmakers divided Medicare into two parts: inpatient and outpatient coverage. Medicare guidelines for covering almost any procedure focus on whether the procedure is medically necessary.

Understanding Insurance Coverage And Weight Loss Surgery

Today in the United States, weight loss surgery is often considered medically necessary to combat obesity. Bariatric surgery helps reduce the overall size of your stomach so you feel full sooner and eat less food. Medicare offers coverage for several weight loss procedures.

Medicare will cover some or all of the following procedures: gastric bypass, gastric band surgery, sleeve gastrectomy, and duodenal switch. However, it will not cover any procedures that you consider “experimental.”

To help doctors determine if a beneficiary is eligible for weight loss surgery, Medicare has criteria that a patient must meet for Medicare to cover bariatric surgery.

To get prior approval for weight loss surgery under Medicare, your doctor must write a letter recommending the surgery and must certify that you meet the following criteria:

Is Bariatric Surgery Covered By Insurance?

Medicare beneficiaries must also have weight loss surgery at facilities that have been certified by the American College of Surgeons as a Level 1 Surgical Center.

Many of those who qualify for bariatric surgery will also qualify for treatment under their Medicare plan. However, this may not be true for everyone. Those with a BMI over 40 but no obesity-related medical conditions may not qualify for the above requirements. You will need to check with your doctor and Medicare to see if you meet the above requirements.

Medicare Part A will cover the hospital stay related to your bariatric surgery. Whenever you have a hospital stay, you are responsible for the Part A deductible, which is $1,340 in 2018. This deductible is set by Medicare each year and generally increases a little annually.

Will Insurance Cover Bariatric Surgery

After this deductible, you will not owe anything else for your hospital stay unless your stay lasts more than 60 days, which would be very unlikely in the case of weight loss surgery.

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Part A also covers blood transfusions, home health care services during an inpatient stay, and skilled nursing facility care for up to 100 days.

Most Medicare beneficiaries pay nothing for Part A because their FICA taxes during their working years pay in advance for their future Part A coverage.

Automatically enrolled if you have paid 10 or more years (40 calendar quarters) of social security taxes. If you have worked less and therefore paid less into social security, you will have to pay a premium. Part A primarily covers the most medically necessary hospital, skilled nursing, home health, and hospice expenses.

Medicare Part B covers outpatient services such as doctor visits, lab tests, diagnostic tests, durable medical equipment, surgery costs, ambulance, medical supplies, mental health care, and much more.

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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 coinsurance.

Most Medicare beneficiaries pay the standard monthly Part B premium, which is $134 per month in 2018. However, some beneficiaries may pay more if they are in a higher income level. Beneficiaries earning more than $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 family gross income from two years ago.

Part B is not automatically enrolled; You will have to pay a monthly premium for this coverage. In 2016, the cost of Medicare Part B is about $104.90 each month, but it depends on your adjusted gross income. Those with higher incomes will typically pay more, from $121.80 for those earning less than $170,000 (filing jointly) to $389.90 if they earn more than $428,000 jointly.

Will Insurance Cover Bariatric Surgery

Medicare Part B covers medically necessary doctor’s fees, including doctor visits, preventive care, durable medical equipment, outpatient hospital services, lab tests, x-rays, mental health care, and some home health care and ambulance services .

Does Medicare Cover Bariatric Surgery?

Medicare Part C is part of the Medicare Policy that allows third-party healthcare companies to provide Medicare benefits. This allows users to access HMOs and PPOs, which are called Medicare Advantage Plans.

Medicare Part D covers outpatient prescription drugs. So, for example, if you were prescribed short-term pain medication after Medicare-covered weight loss surgery, you could 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 co-payment when you pick up the medications.

Part D is the part that covers prescription drug insurance. Prescription drug coverage can only be provided through third-party insurance companies. If you have original Medicare, which is provided through the government, you will need 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.

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You will also need to have Medicare Part A and Part B to pay for medical evaluations and hospital fees. Additionally, depending on your post-operative medications, you may need to purchase drug coverage.

Although Medicare will not cover 100% of any treatment, Medicare may cover part or all of your bariatric surgery as long as you qualify. It will only cover medical surgeries that are considered medically sound, including:

Any surgical procedure other than those listed above is considered “experimental,” meaning it will not be covered by Medicare. This includes the gastric balloon procedure, which is an effective weight loss tool but is still in the early stages of research in the United States.

Will Insurance Cover Bariatric Surgery

Additionally, Medicare can help pay for some of the additional needs of patients undergoing this type of procedure, including initial consultations, hotel stays, nutritional counseling, exercise counseling, and follow-up visits.

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Since Medicare beneficiaries are responsible for deductibles and coinsurance related to Parts A and B, most people sign up for additional coverage to help cover these costs. A variety of insurance companies offer Medicare supplement plans, and these will especially help pay the 20% coinsurance 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 easier 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 the Part B deductible. This means that between Part B and your Medigap plan, many of your costs would be covered at 100%.

Medicare criteria for weight loss surgery may prevent some people from having coverage. Similarly, some people may want to undergo cosmetic surgery after losing weight to get rid of

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