Will My Insurance Cover Bariatric Surgery – Weight loss is a journey — and bariatric surgery is a tool patients use to achieve healthier and often happier lives. Insurance coverage is usually an important financial component 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, Trinity bariatric surgeon and Director of Metabolic and Bariatric Surgery for the Catholic Health system. “That doesn’t happen all over the country, but in New York, it happens.”

Will My Insurance Cover Bariatric Surgery

Will My Insurance Cover Bariatric Surgery

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

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Major insurance providers often have several requirements that bariatric patients must meet before coverage is provided for weight loss procedures.

Trinity Bariatric Surgery has done this in the past, and will continue to adapt our services to better meet the needs of our patients, in addition to their insurance companies. We have done this by making general insurance requirements part of our preoperative process.

Our bariatric surgery team makes every effort to support patients seeking insurance coverage for bariatric surgery. Additional support is provided by:

Updates made by insurance companies may impact the requirements patients must meet before applying for coverage. In this regard, we have seen some insurance providers make changes to their bariatric surgery requirements early in the 2020 calendar year.

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It is commonplace for insurance companies to require significant weight loss efforts with 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 determined by insurance. It can range from 3 months to a full year.

While our office team cannot customize 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 comfortable in the months leading up to surgery.

To find the phone number, address and hours of operation for one of our locations, please visit our locations page.

Will My Insurance Cover Bariatric Surgery

If your message relates to a medical emergency, please call 911 or go to the nearest emergency room. When Congress designed Original Medicare in the sixties, health insurance coverage in America was different than it is today. Our legislators divided Medicare into two parts: hospital and outpatient coverage. Medicare’s guidelines for covering almost any procedure center on whether the procedure is medically necessary.

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Today in America, 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 earlier and eat less. Medicare offers coverage for some weight loss procedures.

Medicare will cover some or all of the following procedures: gastric bypass, lap band surgery, sleeve gastrectomy, and duodenal replacement. However, this agreement does not cover any procedures that are considered “experimental.”

To help doctors determine whether a beneficiary is eligible for weight loss surgery, Medicare has criteria that patients must meet in order for Medicare to cover bariatric surgery.

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

Is Bariatric Surgery Covered By Insurance?

Medicare beneficiaries must also undergo weight loss surgery at a facility that has been certified by the American College of Surgeons as a Level 1 Surgery Center.

Many of those who qualify for bariatric surgery also qualify for treatment under their Medicare plan. However, this may not apply to everyone. Those who have a BMI above 40 but do not have obesity-related medical conditions may not meet the above requirements. You should check with your doctor and Medicare to see if you meet the above qualifications.

Medicare Part A will cover inpatient costs associated with your bariatric surgery. Each time you have an inpatient stay, you are responsible for the Part A deductible, which is $1340 in 2018. This deductible is set annually by Medicare and usually increases slightly each year.

Will My Insurance Cover Bariatric Surgery

After this reduction, there is no further inpatient debt unless your stay is longer than 60 days, which is very unlikely for weight loss surgery.

Bariatric Surgery Checklist

Part A also covers blood transfusions, home health services during hospitalization, and care in a skilled nursing facility for up to 100 days.

Most Medicare beneficiaries pay nothing for Part A because their FICA taxes during the work year prepay future Part A coverage.

Enrolled automatically if you have paid social security taxes for 10 years or more (40 calendar quarters). If you work less and thus pay less into Social Security, you will have to pay a premium. Part A primarily covers the most medically necessary costs of hospital, skilled nursing, home health, and hospice care.

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

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Part B will pay 80% of the cost of your outpatient costs. You are responsible for the annual deductible ($183 in 2018), and the other 20% not covered by Medicare. This is called your coinsurance.

Most Medicare beneficiaries pay the standard monthly premium for Part B, which is $134/month in 2018. However, some beneficiaries may pay more if they are in a higher income bracket. Beneficiaries who earn more than $85,000 as an individual or $170,000 as a married couple will pay the Income-Related Monthly Adjustment Amount (IRMAA). This additional premium will be based on your modified and adjusted gross household income from the past two years.

Part B is not automatically enrolled, you must pay a monthly premium for this coverage. In 2016, the cost of Medicare Part B is approximately $104.90 each month, but depends on your adjusted gross income. Those with higher incomes will typically pay more, ranging from $121.80 for those making less than $170,000 (filing jointly) to $389.90 if you make more than $428,000 jointly.

Will My Insurance Cover Bariatric Surgery

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

Bariatric Surgery Insurance Coverage Options

Medicare Part C is the 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 are called Medicare Advantage Plans.

Medicare Part D covers outpatient prescription drugs. So, for example, if you were prescribed short-term pain medication after weight loss surgery that Medicare covers, you would fill the medication at your local pharmacy using your Part D drug card. This gives you access to medications at a much lower cost than retail prices. You are responsible for co-payments when you take the medication.

Part D is the part that covers prescription drug insurance. Prescription drug coverage can only be provided through a third-party insurance company. If you have original Medicare, which is provided through the government, you must 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 the plan options available in your state by using the Medicare Plan Finder Tool.

What If My Insurance Doesn’t Cover Weight Loss Surgery?

You are also required to have Medicare Part A and Medicare Part B to cover the doctor’s evaluation and hospital costs. Additionally, depending on post-operative medications – you may need to purchase drug coverage.

Although Medicare does not cover 100% of any treatment, it may cover some or all of your bariatric surgery as long as you qualify. It only covers medical operations that are considered medically sound, including:

Any surgical procedures other than those listed above are considered “experimental,” meaning they are not 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 My Insurance Cover Bariatric Surgery

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

Insurance And Bariatric Surgery: How To Navigate Your Benefits

Because Medicare beneficiaries are responsible for the deductible and coinsurance associated with Parts A and B, most individuals enroll in additional coverage to help cover these costs. Medicare Supplement Plans are offered by various insurance companies, and they will primarily help pay for the 20% coinsurance you will have to pay 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 the Part B deductible. This means that between Part B and your Medigap plan, most of your costs will be covered 100%.

Medicare criteria for weight loss surgery may prevent some individuals from obtaining coverage. Likewise, some people may require cosmetic surgery to remove the weight afterward

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