Will Medicare pay for bariatric surgery?
Read this engaging article to the end to find out.
If you are struggling with obesity and considering bariatric surgery, you may wonder if Medicare will cover the cost of your procedure.
Medicare is a federal health insurance program that provides coverage for various health services, including some types of bariatric surgery.
But will Medicare pay for your bariatric surgery?
The answer depends on several factors, such as your eligibility, the type of surgery, and the costs involved.
In this article, we will explain everything you need to know about Medicare and bariatric surgery.
Eligibility for Coverage
Medicare does not cover bariatric surgery for everyone.
You need to meet certain criteria to qualify for coverage.
These criteria include:
- Body Mass Index (BMI): Your BMI is a measure of your body fat based on your height and weight. Medicare requires you to have a BMI of at least 35 to be eligible for bariatric surgery. This means that you have a higher weight and are at a high risk of health problems. A lower BMI may be accepted if you have other medical conditions that are related to your obesity.
- Comorbidities: These are obesity-related conditions that affect your health and quality of life. Examples of comorbidities are diabetes, sleep apnea, and heart disease. Medicare requires you to have at least one comorbidity to be eligible for bariatric surgery. This shows that your obesity is not only a cosmetic issue but a serious health concern that needs treatment.
- Prior weight loss attempts: Medicare requires you to have tried and failed to lose weight through non-surgical methods, such as diet, exercise, and medication. You need to provide documentation of your weight loss attempts, such as medical records, prescriptions, or receipts. This shows that you are committed to improving your health and that surgery is your last resort.
- Pre-surgical evaluation: Medicare requires you to undergo a comprehensive evaluation before surgery to assess your physical and mental readiness. This evaluation includes psychological and nutritional assessments, as well as tests for blood pressure, blood sugar, and liver function. This ensures that you are a suitable candidate for surgery and that you can handle the post-surgical changes.
Covered Surgical Procedures
Medicare covers three types of bariatric surgery: gastric bypass, sleeve gastrectomy, and an adjustable gastric band.
These procedures are performed laparoscopically, which means that they use small incisions and instruments to reduce the size of your stomach and/or change the way your digestive system works.
Here is a brief overview of each procedure:
- Gastric bypass: This is the most common and effective type of bariatric surgery. It involves creating a small pouch from the upper part of your stomach and connecting it to the lower part of your small intestine. This bypasses a large portion of your stomach and intestine, reducing the amount of food you can eat and the calories you can absorb.
- Sleeve gastrectomy: This is a newer and simpler type of bariatric surgery. It involves removing about 80% of your stomach, leaving a narrow tube or sleeve. This reduces the amount of food you can eat and the hunger hormones you produce.
- Adjustable gastric band: This is the least invasive and reversible type of bariatric surgery. It involves placing a silicone band around the upper part of your stomach, creating a small pouch. The band can be tightened or loosened to adjust the size of the pouch and the amount of food you can eat.
Each procedure has its advantages and disadvantages, and the best option for you depends on your case.
You should discuss the pros and cons of each procedure with your doctor and surgeon before making a decision.
Costs and Out-of-Pocket Expenses
Medicare does not cover the entire cost of bariatric surgery.
You will still have to pay some out-of-pocket expenses, such as deductibles, copays, and coinsurance.
The amount you pay depends on which part of Medicare you have and where you get your surgery.
- Part A: This is the part of Medicare that covers hospital services, such as inpatient care, skilled nursing facility care, and hospice care. If you have Part A, you will have to pay a deductible of $1,484 for each benefit period in 2024. You will also have to pay coinsurance of $371 per day for days 61–90 of each benefit period and $742 per day for days 91 and beyond of each benefit period. These amounts may change each year.
- Part B: This is the part of Medicare that covers medical services, such as doctor visits, lab tests, and outpatient care. If you have Part B, you will have to pay a monthly premium of $148.50 in 2024. In 2024, you will also have to pay a deductible of $203. After you meet your deductible, you will have to pay 20% of the Medicare-approved amount for most services.
- Medigap: This is a type of supplemental insurance that helps pay some of the costs that Medicare does not cover, such as deductibles, copays, and coinsurance. There are 10 standardized Medigap plans, each with different levels of coverage and costs. If you have a Medigap plan, you may pay fewer out-of-pocket expenses for your bariatric surgery. However, not all Medigap plans cover bariatric surgery, and some may have restrictions or limitations.
The total cost of bariatric surgery can vary widely depending on the type of procedure, the hospital, the surgeon, and the region.
According to the American Society for Metabolic and Bariatric Surgery, the average cost of bariatric surgery in the United States ranges from $14,000 to $23,000.
However, this does not include the costs of pre-surgical and post-surgical care, such as evaluations, tests, follow-ups, medications, and supplements.
Resources and Next Steps
If you are interested in getting bariatric surgery with Medicare, you should start by doing some research and gathering some information.
Here are some helpful resources for you:
- Official Medicare website: This is the best place to find accurate and up-to-date information about Medicare coverage, costs, and eligibility. You can also compare plans, find providers, and enroll online.
- Bariatric surgery societies: These are professional organizations that promote the standards and quality of bariatric surgery. They also provide educational and support resources for patients and surgeons. Some of the most reputable societies are the American Society for Metabolic and Bariatric Surgery, the International Federation for the Surgery of Obesity and Metabolic Disorders, and the Obesity Society.
- Patient support groups: These are groups of people who have undergone or are considering bariatric surgery. They offer emotional and practical support, share experiences and tips, and answer questions. You can find local or online support groups through your doctor, hospital, or bariatric surgery society.
The next step is to talk to your doctor and Medicare provider about your specific situation and options.
Your doctor can help you determine if you are a good candidate for bariatric surgery, which procedure is best for you, and what risks and benefits are involved.
Your Medicare provider can help you understand your coverage, costs, and eligibility and guide you through the approval process.
Before making a decision, ensure you are fully informed and prepared by asking as many questions as you can.
Bariatric surgery can be a life-changing option for people who suffer from obesity and its related health problems.
Medicare can help pay for some of the costs of bariatric surgery, but not for everyone.
You need to meet certain criteria to qualify for coverage, and you will still have to pay some out-of-pocket expenses.
You also need to choose the right type of procedure for your case and be aware of the risks and benefits involved.
Bariatric surgery is not a quick fix or a magic solution.
It requires a long-term commitment to lifestyle changes and follow-up care.
However, if you are ready and willing to take this step, bariatric surgery can offer you a better quality of life and a healthier future.
We hope this article has answered your question: Will Medicare pay for your bariatric surgery?
If you want to learn more, please visit the resources we have provided and talk to your doctor and Medicare provider.
We wish you all the best on your journey.
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I am Evans, an insurance expert with a deep-rooted passion for helping people understand the world of insurance. With about 2 years of experience, I’ve dedicated my career to simplifying complex insurance concepts and providing tailored solutions. I have the knowledge and expertise to guide individuals and businesses in making informed insurance decisions, thanks to my educational background in finance and risk management and my Bachelor’s degree in Insurance and Risk Management from Columbia University. I believe that insurance is not just about policies; it’s about safeguarding dreams and ensuring financial security. I’m committed to sharing my insights and knowledge to empower others to protect what matters most.