Weight loss surgery is considered an elective procedure, defined as a surgery that “may be delayed for months without threat to life or organ damage.” Yet, surgeons and medical professionals recognize the dangerous effects of obesity, urging insurance plans to change their policies to support bariatric coverage. Due to the decreased quality of life and the higher cost of care in treating the health of overweight or obese individuals, there is more insurance coverage for weight loss surgery today than ten years ago.
In 2012, with the Affordable Care Act (ACA), states were given more freedom in choosing statewide insurance plans that would provide more in-depth coverage for patients. This resulted in the U.S. Department of Health and Human Services establishing a federal default known as the Essential Health Benefit (EHB) Benchmark Plan. The EHB established guidelines for diagnosing and treating obesity, including bariatric surgery and/or nutrition counseling and therapy.
Yet, Georgia, Indiana, and Virginia redlined the policy to allow coverage to be offered but not required for all insurance plans. There is good news for Georgia residents, though—in the beginning of 2022, Georgia began offering state employees full coverage for weight loss surgery! Schedule an appointment today to get started on your bariatric journey.
Finding Insurance Coverage for Weight Loss Surgery
At Live Healthy MD, we accept all major commercial insurance carriers as well as Medicare and Medicaid. However, the degree to which your insurance plan will cover the procedure is based on a few factors, including the type of insurance plan you have.
- Individual/Family or Small Group Policy: Coverage through an employer with under 50 employees. This plan covers weight loss surgery if you live in one of the 23 states where it is mandated.
- Large Group Policy: Coverage through an employer with 50+ employees. This plan covers weight loss surgery if your employer has opted in for it.
- Medicare: This is a covered benefit in every state.
- Medicaid: This is a covered benefit of weight loss surgery in most states; however, not all surgeons accept Medicaid.
Check out this list for a complete list of insurances that cover weight loss surgery. We also recommend calling your insurance plan to discuss the exact coverage details. You can find the number on the back of your insurance card.
Once on the phone, ask the representative if your insurance plan includes obesity treatment and/or weight loss surgery as a covered benefit. And before hanging up, be sure to ask for a copy of the benefits plan via email to verify the coverage by looking specifically for bariatric services.
If you have any questions regarding this process and the insurances that cover weight loss surgery, you can reach out to one of our partnered bariatric clinics.
When you request an appointment with our practice, the clinical care team will gather your insurance information and give your insurance company a call to find out your specific bariatric insurance benefits and coverage. Your clinical navigator will then provide you with all the information you need to make an informed financial decision before your initial consultation.
If your insurance does not cover weight loss surgery, other self-pay options are available.
Requirements of Insurance Coverage for Weight Loss Surgery
Before having your insurance company pay for the bariatric procedure, you may have to complete the following criteria:
*(Note that the criteria will vary between different insurance providers)
- Medically supervised diet for a consecutive monthly period.
- Proof of tried and failed weight loss attempts
- Nutritional and psychological evaluations
- Documentation of weight-related medical problems
Similarly, you will need to have a body mass index (BMI) greater than 35 with weight-related medical conditions or a BMI of 40+ without weight-related comorbidities.
Costs Associated with the Insurances that Cover Weight Loss Surgery
If your insurance plan does cover weight loss surgery, there will be several costs that you should be aware of.
The individual’s monthly bill that is paid to access the health insurance plan at any time of need.
How much an individual needs to pay for health care services out of pocket before health insurance kicks in. Once the deductible is paid, the patient will still need to pay the copay and coinsurance. Typically, the lower the premium, the higher the deductible.
The fixed amount you pay for a specific service or prescription medication. Copayments are one of the ways that health insurers will split costs with you after you hit your deductible. In addition to that, you may have copayments on specific services before you hit your deductible.
For example, many health insurance plans will have copayments for doctor’s visits and prescription drugs before you hit your deductible. You will pay copayments until you hit your maximum out-of-pocket amount.
4. Maximum out-of-pocket amount
The maximum out-of-pocket amount, also called the out-of-pocket limit or catastrophic limit, is the most you’d ever have to pay for covered health care services in a year.
Payments made towards your deductible and any copayments and coinsurance payments go toward your out-of-pocket limit, but monthly premiums do not.
Coinsurance is another way that health insurers will split costs with you. Unlike a copayment, coinsurance is not a fixed cost – it’s a percentage of the cost you pay for covered services. For example, if you have a coinsurance of 20%, you’ll pay 20% of the cost of covered services until you reach your out-of-pocket maximum.
The cost of weight loss surgery is more than just the surgery itself. In addition to the procedure, you will need to consider the costs associated with pre-surgery requirements and post-surgery lifestyle changes. These post-surgery changes can include buying more clothes after losing an extreme amount of weight and purchasing healthy food to go along with your new lifestyle.
This article was originally published on the Bariatric Centers of America website.