Medicaid & Medicare Bariatric Surgery Coverage
Medicare bariatric surgery has been approved, but certain caveats apply. Below we’ll review…
- What are Medicare, Medigap and Medicaid?
- Bariatric surgery for people 65 and older – is it safe and effective?
- Caveats for Medicare to approve bariatric surgery
- How to apply for Medicare or Medigap coverage
Medicare is a U.S. government-controlled health care program for people…
- 65 or older
- Under 65 with certain disabilities
- Any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)
Medicare has four separate parts, including:
- Part A (Hospital insurance) – Qualifying individuals are usually automatically enrolled in part A unless explicitly choosing to enroll in a Medicare Advantage plan (Part C). Part A covers inpatient hospital and skilled nursing facility care, home health services and hospice care (not long-term custodial care).
As long as you or your spouse paid Medicare taxes during your working life, Part A will usually be offered at no charge. You also have the choice of paying for Part A (as a part of a Medicare Advantage plan, for example).
- Part B (Medical insurance) – Part B covers outpatient care, doctor office visits, home health and some preventive services. If you receive Social Security or Railroad Retirement Board benefits, you will be automatically enrolled in Part B. Unless you opt out by sending the Medicare card back when it arrives, you will be billed accordingly.
- Part C (Medicare Advantage program) – Medicare Advantage offers the benefits included under Part A and Part B in addition to other benefits such as prescription drugs, dental, vision or hearing. They also offer options to lower your out-of-pocket costs when using the plan. Most of plans require that you use a special network of doctors and hospitals (i.e. HMO, PPO, etc.).
Medicare Advantage is offered through insurance companies that have been approved by the government, although it is not available in all states.
- Part D (Prescription drug coverage) – Medicare prescription drug coverage is available to everyone enrolled in Medicare and is offered through private companies that have been approved by the government. Medicare-eligible individuals have the option of purchasing Part D along with the traditional Parts A and B or as a part of a Medicare Advantage plan (Part C).
Medigap, also known as Medicare Supplemental Insurance, covers costs that Parts A through D do not. As with Medicare Advantage, as long as you qualify for Medicare you can purchase Medigap coverage through approved insurance companies or a broker that represents them.
Medicaid programs are state-run programs established for low-income individuals or families. Medicaid pays medical benefits directly to providers (doctors, hospitals, pharmacies, etc.) for “Qualified Medicare Beneficiaries.” If you qualify, each state has its own requirements and may or may not pay for the surgery.
There are contradicting opinions about whether or not weight loss surgery is safe and effective for people 65 years of age and older…
- One 2009 study evaluated 100 patients over the age of 65 and found that bariatric surgery for seniors has similar benefits and no additional risks compared to patients under 65. Their results showed that morbidly obese patients over 65 have shorter hospital stays following bariatric surgery than younger patients. The same study showed that after two years older patients lost almost 76% of their excess weight.
- However, a much larger 2006 aggregate study (over 25,000 total patients) showed that seniors experience less weight loss and more complications than younger patients and concluded that, "Limiting bariatric surgical procedures to those younger than 65 years is warranted because of the high morbidity and mortality associated with these operations in older patients."
to the Centers for Medicare and Medicaid Services
“The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is adequate to conclude that open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), [laparoscopic sleeve gastrectomy (gastric sleeve surgery - added to covered bariatric surgeries in 2012)], and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS), are reasonable and necessary for Medicare beneficiaries who have a body-mass index (BMI) > 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.”
Take a look at the CMS web site to read their entire opinion.
The takeaway is that bariatric surgery may be appropriate for people over 65 depending each individual’s situation, but it is likely that a lower percentage of seniors will qualify for surgery than those under 65 years of age.
The best way to determine whether surgery is right for you is to discuss it with your primary care physician and a reputable local weight loss surgeon.
Most surgeons offer free seminars that teach you about your options and their office's specific results. The seminars also allow you to get to know the surgeon prior to a one-on-one consultation (usually free as well).
Medicare has determined that bariatric surgery is appropriate for the treatment of obesity as long as the patient has…
- A body mass index (BMI) greater than 35 (see our BMI Formula page for more on body mass index)
- At least one co-morbidity related to obesity
- Has documentation in their medical records confirming that previous attempts at medical treatment for obesity have been unsuccessful
If all of the above apply, the surgery must be one of the following types…
- Gastric bypass surgery (open or laparoscopic)
- Lap band surgery (laparoscopic only)
- Gastric sleeve surgery (laparoscopic only)
- Biliopancreatic diversion with duodenal switch (BPD/DS) (open or laparoscopic)
To get approved, you’ll need to be referred by your primary care physician or other attending doctor (probably not just a self-referral to a bariatric surgeon). In their referral to a bariatric surgeon, your physician should refer to the obesity health problems that are expected to improve after surgery.
Bariatric Surgery Facility Certification (Center of Excellence) Requirements
The Centers for Medicare and Medicaid Services (CMS) no longer require weight loss surgery hospitals and facility to be designated Centers of Excellence in order to be covered.
According to CMS, "the evidence is sufficient to conclude that continuing the requirement for certification for bariatric surgery facilities would not improve health outcomes for Medicare beneficiaries. Therefore, CMS has decided to remove this certification requirement."
For more information about the change, click here.
If you obtain/have traditional Medicare coverage, you'll need to choose a facility that meets the Centers for Medicare and Medicaid Services’ minimum facility standards and certification requirements for Medicare bariatric surgery. Click here to search their directory.
If you choose/have Medicare Advantage, you'll need to verify that your chosen surgical team and their hospital are in your insurance company's network. Call your insurance company directly to find out.
Regardless of which Medicare plan you have or are applying for, talk with your surgeon to find out if they accept Medicare/Medicare Advantage. They may have some especially useful tips on how to streamline the process with Medicare Advantage insurance companies in your area.
Applying for coverage for a Medicare plan depends on your goals and situation. As long as you meet the eligibility criteria described above, following are your options:
- Part A (Hospital insurance) – As explained above, qualifying individuals are usually automatically enrolled in part A unless explicitly choosing to enroll in a Medicare Advantage plan (Part C described below).
As long as you or your spouse paid Medicare taxes during your working life, Part A will usually be offered at no charge.
You also have the choice to pay for Part A as a part of a Medicare Advantage plan.
- Part B (Medical insurance) – If you receive Social Security, you will be automatically enrolled in Part B.
If you do not, you can apply for both Social Security and Medicare at the same time three months before the month you turn 65. See Medicare.gov for more information.
You can also enroll in Part B via a Medicare Advantage program...
- Part C (Medicare Advantage program) – If you want more robust benefits than Parts A and B offer including prescription drugs, dental, vision or hearing and the option for lower out-of-pocket costs for doctor and hospital visits, Medicare Advantage is the way to go.
- Part D (Prescription drug coverage) – To obtain Medicare Prescription Drug coverage, you are required to have Medicare Part A and/or Part B. To get prescription drug coverage through a Medicare Advantage Plan, enrollment in Part A and Part B is mandatory. Call (800)MEDICARE for traditional plans or work with your Medicare Advantage plan to add it to your Medicare Advantage policy.
- Medigap - Just like Medicare Advantage, Medicare Supplement Plans are offered through government-approved insurance companies. While you can work with insurance companies directly, we recommend working with a qualified broker to help you compare multiple insurance companies and choose the option that's best for you.
- Schedule a free seminar or one-on-one consultation with a qualified weight loss surgeon in your area
- Financing bariatric surgery (without Medicare bariatric surgery or other insurance)
- How to find, interview and choose the best bariatric doctors