Medicare covers bariatric surgery for beneficiaries diagnosed with morbid obesity. Weight loss surgery is considered when a person’s obesity has been detrimental to their health and all other forms of weight management have been ineffective.
- Bariatric surgeries change a person’s digestive system to help them lose weight.
- Bariatric surgeries require permanent lifestyle changes to the recipient’s diet and physical activities to make the surgery effective.
- Medicare will cover bariatric surgery for beneficiaries with morbid obesity.
- Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). cover bariatric surgeries, but the beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. will have to use providers within the plan.
- MedigapMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. policies can provide help with bariatric surgery costs after Medicare has provided coverage.
What Is Bariatric Surgery?
Bariatric surgery is a medical procedure that makes changes to a person’s digestive system to facilitate weight loss. Bariatric surgery is considered if dietary changes and exercise were ineffective for weight loss and the weight is causing significant health problems. Types of bariatric surgeries include:1Mayoclinic.org, “Bariatric surgery“, Accessed October 29, 2021
- Gastric Bypass Surgery
- Laparoscopic Banding (Lap-Band Surgery) or Realize Band Surgery
- Duodenal Switch
- Sleeve Gastrectomy
All weight-loss surgeries are major procedures that carry significant risks to the recipient. A full lifestyle change must be made to the person’s dietary and activity habits after surgery to enable the positive effects of the procedure.1Mayoclinic.org, “Bariatric surgery“, Accessed October 29, 2021
How Does Medicare Cover Bariatric Surgery?
Medicare covers bariatric surgeries if the beneficiary meets the following eligibility conditions for morbid obesity:
- BMI (body mass index) of 35 or greater.
- At least one co-morbidity – a serious illness directly related to their obesity, such as:
- High blood pressure
- Type 2 diabetes
- Sleep apnea
- Documented evidence that the beneficiary has been obese for the last 5 years.
- Documented participation in a medically supervised weight loss program.
- A letter from the beneficiary’s physician recommending or supporting a weight loss procedure.
- Passed a psychological evaluation.
- All other treatable medical conditions have been ruled out as a possible cause of obesity.
Bariatric surgeries are a major invasive surgical procedure, so the beneficiary will likely be admitted to an inpatient hospital covered by Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care.. The beneficiary may instead receive bariatric surgery in a hospital outpatient department, which would be covered by Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services..2Medicare.gov, “Bariatric surgery“, Accessed October 29, 2021
How Much Does Bariatric Surgery Cost?
The cost of the bariatric surgery will depend on the area and what type of bariatric surgery is being done. According to the National Library of Medicine, the costs of bariatric surgery can range from $7,423 to $33,541, averaging at $14,389.3ncbi.nlm.nih.gov, “What Are the Real Procedural Costs of Bariatric Surgery? A Systematic Literature Review of Published Cost Analyses“, Accessed November 8, 2021
Increasingly, bariatric surgery is an outpatient procedure that’s covered completely by Medicare Part B. The dominant procedure performed in outpatient surgical centers is the laparoscopic adjustable gastric band (LAGB) procedure, which helps reduce the cost. Medicare covers 80 percent of all approved costs once the beneficiary has paid their annual Part B deductible. If the surgeon, anesthesiologist, or the surgical center charge Part B Excess ChargesA Medicare Part B excess charge is the difference between a health care provider’s actual charge and Medicare’s approved amount for payment., the beneficiary is responsible for these costs.
When a bariatric surgery procedure is performed as an inpatient procedure the hospital costs are covered by Medicare Part A, which has a benefit periodA benefit period is a method used in Original Medicare to measure a beneficiaries use of hospital and skilled nursing facility (SNF) services. With each new benefit period, the beneficiary is charged a new benefit... deductible. However, physician services for non-hospital employees, which generally includes the surgeon and the anesthesiologist, are covered under Part B. Hospital services related to inpatient surgery include things like daily room and board, laboratory services, diagnostic tests, surgical equipment and supplies, anesthesia, and the services of nurses, and other health professionals.
Medicare Advantage plans are required to cover the same services as Medicare Part A and Part B, in addition to any expanded services offered. That includes bariatric surgery. However, a beneficiary’s out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. with a Medicare Advantage plan may be different than those with Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage.. Also, Medicare Advantage plan rules may require their members to use network providers for all services, supplies, and durable medical equipmentDurable medical equipment (DME) is equipment that is designed to last and can be used repeatedly. It is suitable for home use and includes wheelchairs, oxygen equipment, and hospital beds..4Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed October 29, 2021
People with Original Medicare can purchase additional insurance, called Medigap, to help cover their Medicare out-of-pocket costs. Medicare supplement insurance, as it is also known, is available through private insurance companies. Depending on the plan, a Medigap policy will cover some or all of the out-of-pocket costs associated with Medicare-approved bariatric surgery procedures. These costs include:5Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed October 29, 2021
- DeductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.
- CoinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service.
- CopaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.
Post-Surgery Medication Costs
When post-surgery medication is required it will generally be covered by a beneficiary’s Medicare Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... plan. Depending on the Part D plan, members may pay an annual deductible, before the plan begins paying its share, as well as a copayment.6Medicare.gov, “What Medicare Part D drug plans cover“, Accessed November 8, 2021
If you have been diagnosed with morbid obesity and other forms of weight management have been ineffective, consult with your doctor. Bariatric surgery could be the logical next step. If you meet the eligibility conditions, and your doctor orders the procedure, Medicare will pay its share.
- 1Mayoclinic.org, “Bariatric surgery“, Accessed October 29, 2021
- 2Medicare.gov, “Bariatric surgery“, Accessed October 29, 2021
- 3ncbi.nlm.nih.gov, “What Are the Real Procedural Costs of Bariatric Surgery? A Systematic Literature Review of Published Cost Analyses“, Accessed November 8, 2021
- 4Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed October 29, 2021
- 5Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed October 29, 2021
- 6Medicare.gov, “What Medicare Part D drug plans cover“, Accessed November 8, 2021