Does Health Insurance Cover Weight Loss Surgery?
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Affordable Care Act (ACA) Marketplace health plans are required to cover weight loss surgery in 23 states and many ACA-compliant plans outside of those states may also provide coverage. In addition, Medicare and Medicaid may cover bariatric surgeries for members who meet certain eligibility requirements.
Keep reading for more information on when health insurance covers weight loss surgery including what surgeries are typically eligible and what steps you may need to take to qualify for coverage.
What Types of Weight Loss Procedures Are There?
There are three main types of bariatric surgery performed for the purpose of treating obesity by managing weight. See the below table for a description of each of the primary surgical treatments for obesity.
This procedure involves the removal of about 80% of your stomach in order to limit the amount of food your stomach can hold at one time and make you feel full more quickly
There are three steps a surgeon will take when performing gastric bypass surgery:
Adjustable Gastric Band
The surgeon will insert a ring with an inflatable band into your stomach in order to make you feel full faster and then adjust the size of the band as necessary over the course of several follow-up visits
There is also a less common health care option known as biliopancreatic diversion with duodenal switch. This is basically a combination of gastric sleeve and gastric bypass surgery as it involves the removal of most of your stomach followed by the division of your small intestine so that food will bypass most of it, causing your body to absorb fewer nutrients and calories.
Biliopancreatic diversion with duodenal switch can result in a greater amount of weight loss than the three main types of bariatric surgery but it is also more likely to lead to surgery-related complications. As a result, this procedure is usually reserved for patients experiencing severe health problems related to obesity.
Which Weight Loss Procedures Are Covered by Insurance?
Marketplace health insurance plans are required to broadly cover bariatric surgery in 23 states. Coverage is not guaranteed outside of these states, although many health insurance companies across the country may still opt to cover the major types of weight loss surgery.
Medicare similarly covers major weight loss operations, although coverage sometimes depends on whether it is an open surgery that requires a large incision or a laparoscopic surgery that requires a small incision. Specifically, Medicare will help eligible members pay for the following procedures:
- Open or laparoscopic gastric bypass surgery
- Open or laparoscopic biliopancreatic diversion with duodenal switch or gastric reduction duodenal switch
- Laparoscopic adjustable gastric band surgery (also known as lap-band surgery)
- Laparoscopic gastric sleeve surgery (only if approved by your region’s Medicare Administrative Contractor)
Medicaid may also cover various weight loss surgeries, although exact benefits vary by state. For example, Medicaid members in North Carolina who meet certain criteria can receive coverage for adjustable gastric band surgery, biliopancreatic diversion with or without duodenal switch, laparoscopic gastric sleeve surgery or gastric bypass surgery with the option to have a larger portion of the small intestine connected to the stomach pouch depending on the patient’s body mass index (BMI).
Does Insurance Cover Gastric Sleeves?
Individual and small group health insurance plans that help pay for bariatric surgeries should generally include insurance coverage for gastric sleeve surgery. Conversely, Medicare places more restrictions on when members can receive coverage for gastric sleeves.
In addition, Medicare expressly excludes coverage for open gastric sleeve surgery.
How Can I Get Insurance To Cover Weight Loss Surgery?
Your insurance carrier may impose certain eligibility qualifications before agreeing to cover your weight loss surgery. Examples of requirements you could have to meet to qualify for bariatric surgery coverage include the following:
- Being a legal adult
- Having a BMI above 40 or having a BMI between 35 and 40 plus another risk factor like type 2 diabetes or high blood pressure
- Showing evidence that you have made efforts to lose weight over a specified period of time
- Participating in an insurer-required weight loss program
- Undergoing psychological testing
- Quitting smoking before your surgery
- Demonstrating no signs of substance abuse
- Getting diagnosed with morbid obesity prior to your surgery
If your employer-sponsored health plan initially denies coverage for a weight loss surgery, you could get your health care provider to send a letter to your employer’s human resources department explaining why you need a certain bariatric procedure and asking for your plan to add coverage for that procedure.
Depending on the state you live in, it’s possible that your current health insurance will not cover weight loss procedures under any circumstances. In this case, you may want to shop for a plan that will cover bariatric operations during open enrollment or a special enrollment period if you are eligible for one.
Medicare and Medi-Cal
Government-funded health insurance programs also typically set requirements you must meet to qualify for bariatric surgery coverage. For example, Medicare will only cover approved surgeries if you have a BMI of 35 along with at least one other obesity-related condition and have undergone medical treatment for obesity in the past to no avail.
Meanwhile, members of California’s Medicaid program, Medi-Cal, can only receive coverage for applicable surgeries if they meet the following prerequisites:
- Sending in a Treatment Authorization Request (TAR) to get the surgery approved
- Having a BMI of at least 40 or having a BMI between 35 and 40 plus a comorbidity
- Documenting the failure of prior weight loss treatments
- Establishing a comprehensive treatment plan for before and after the surgery
- Lacking any physical or psychological conditions that would make the surgery unsafe
How Much Does Weight Loss Surgery Cost Without Insurance?
Without insurance, the average cost of weight loss surgery was between $17,000 and $26,000 in 2021. Factors that can influence the exact price include the type of surgery you get, the facility you stay in and what other services you receive alongside the surgery. For example, the University of Utah Hospital charges patients who pay without insurance $21,583 for gastric bypass surgery and $19,354 for gastric sleeve surgery.