Does Medicare Cover Bariatric Weight Loss Surgery?
Yes, Medicare does cover some bariatric weight loss surgery, including gastric bypass and laparoscopic banding procedures. Qualifying criteria for bariatric surgery on Medicare include a body mass index (BMI) of 40 or higher or a minimum 30 BMI with another chronic health condition.
You may receive coverage through Medicare Parts A or B, depending on whether you choose inpatient or outpatient bariatric surgery, respectively. Medicare Advantage (Part C) will also provide equivalent and possibly additional coverage.
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The Benefits of Bariatric Surgery
Bariatric surgery helps people with high BMIs lose weight and avoid some of the health problems commonly caused by morbid obesity. While all men and women carry weight differently, anyone with a BMI over 40 is considered morbidly obese and at a higher risk for developing conditions such as the following:
- High blood pressure
- Coronary heart disease
- Sleep apnea
Undergoing weight loss surgery can offer life-altering benefits to patients who are morbidly obese and have tried weight loss counseling and non-surgical alternatives to no avail. Medicare covers bariatric surgery as a medically necessary procedure. Consult your physician and review your Medicare plan to explore bariatric surgery benefits.
Types of Bariatric Surgery
The following are the most common types of bariatric surgery:
- Gastric Bypass Surgery: This surgery forms a smaller pouch out of stomach tissue to limit food intake and forces food to bypass the rest of the stomach via the small intestine, drastically reducing calorie absorption. Gastric bypass suits patients with a high BMI but can also alleviate severe acid reflux.
- Lap-Band Surgery: Laparoscopic adjustable gastric banding surgery creates a narrower passage and smaller pouch for food intake by placing a hollow band around the upper end of the stomach. The surgeon can alter the size of the passage as needed over time. Physicians recommend this surgery for patients with a BMI of at least 35.
- Gastric Sleeve Surgery: Gastric sleeve surgery permanently removes roughly 80% of the stomach volume, creating a narrow “sleeve” or curved tube in its place. This procedure best suits severely obese patients weighing over 450 pounds. Additionally, people with scar tissue from previous surgeries or a high surgical risk tend to see better results with gastric sleeve surgery than gastric bypass.
Understanding Medicare Coverage for Bariatric Surgery
You must meet several specific criteria to be eligible for Medicare-approved bariatric surgery. Your minimum BMI, potentially with one or more comorbid conditions, must fall under the classification of morbidly obese.
Additionally, you must prove the ineffectiveness of other methods to lose weight, reduce your risk for chronic conditions, and lower your BMI.
In order for Medicare to cover your weight loss surgery, you must meet one or more of the following criteria:
- You have a BMI of at least 35 and a comorbid condition related to obesity, such as diabetes, high blood pressure, high cholesterol, or sleep apnea.
- You have joint or back pain or obesity-related soft-tissue infections alongside a high BMI.
You must also meet your Part A and Part B deductibles to use Medicare benefits for weight loss surgery. You should explore your options through Original Medicare or Medicare Advantage to undergo bariatric surgery as an inpatient or outpatient procedure, as this distinction can affect how Medicare pays for your expenses.
Part A Coverage
Medicare Part A covers inpatient care, including hospitalization for bariatric surgery. You must pay your Part A deductible (set at $1,600 in 2023) for Medicare to cover a post-surgery hospital stay of up to 60 days. You must use your Medicare lifetime reserve days to pay a set out-of-pocket rate per day for a hospitalization lasting 61-90 or more consecutive days.
Even if you are required to pay the full Part A deductible to qualify for weight loss surgery, this coverage through Medicare costs much less than the average gastric bypass or gastric banding procedure for a patient without health insurance. Most Medicare beneficiaries qualify for $0 monthly Part A premiums if they paid into Medicare taxes while working for at least 10 years.
Part B Coverage
Part B typically covers outpatient services and preventive medical care. For example, in this case, Part B might cover the doctor visits and weight loss counseling that eventually lead to a recommendation for weight loss surgery. Though less common than an inpatient surgery requiring hospitalization, Part B may also cover an outpatient bariatric procedure if available.
Part B may also cover outpatient services following bariatric surgery, including the following:
- Support garments
- Medical equipment
- Home healthcare
Medicare Post-Bariatric Surgery Coverage
As with any surgery, you run the risk of potentially developing an infection or comorbid condition after a bariatric procedure. A gastric banding or gastric bypass can sometimes cause nutrient or vitamin deficiencies or complications like hernias, hypoglycemia, or chronic kidney disease.
Generally, Medicare Part A covers the care you receive in the hospital immediately following your surgery, while Part B covers outpatient post-surgical care, including follow-up visits. Patients who develop severe complications and remain morbidly obese after surgery may qualify for a bariatric surgery revision on Medicare, provided they meet medical and psychological criteria.
How Does Medicare Advantage Cover Bariatric Surgery?
Medicare Advantage can be purchased separately by anyone already enrolled in Original Medicare and usually offers additional benefits, including vision, dental, and hearing services. Medicare Advantage plans tend to include the same bariatric surgery coverage as Medicare Parts A and B, potentially with additional costs.
Private insurers can set their own rates for Medicare Advantage plans, which means your premium and deductible costs vary depending on your location and other eligibility criteria.
How Much Does Weight Loss Surgery Cost With Medicare?
Medicare Part A covers the cost of hospitalization for inpatient weight loss surgery. Part B may cover the surgery as an outpatient procedure in select Medicare-approved facilities. You must pay your Part A and Part B deductibles before benefits go into effect. Medigap can also help offset some of the out-of-pocket expenses for weight loss surgery.
Type of Surgery
Cost Without Insurance
Cost With Original Medicare
Gastric Bypass Surgery
Gastric Sleeve Surgery
$1,826**Total cost of Medicare Part A and Part B deductibles in 2023. Part A deductible reflects a hospital stay of up to 60 days; inpatient care during days 61-90 requires additional costs.
Medicare Advantage Costs
You can also get coverage for weight loss surgery through Medicare Advantage; however, the premiums and deductibles vary from one plan to the next since private insurers issue these policies. You should review your policy benefits and request a cost estimate for bariatric surgery under your individual Medicare Advantage plan.
Alternatives to Bariatric Surgery
If Medicare does not cover your bariatric surgery, other weight loss options exist. These options might not be suitable for all people, so speak to your physician for advice. Alternates to bariatric surgery include:
- Lifestyle changes: Consider how changes to your lifestyle could ultimately lower your BMI. Changes such as quitting smoking can not only improve your overall health but also motivate you to lose weight and keep it off.
- Diet and nutrition counseling: A proper diet and nutrition are critical to one’s weight loss journey. You might simply need counseling to become educated about how to incorporate healthy eating habits for sustained weight loss over time.
- Exercise and physical activity: Lowering your BMI without bariatric surgery requires increasing your exercise and physical activity levels. Consider starting slow and setting reasonable goals for long term weight loss. You might pair with an accountability coach for added incentive.
- Behavioral therapy: Behavioral therapy can help people replace unwanted behaviors and habits with a healthier response. Behavioral therapy focused on weight loss can help patients “train” their brains to incorporate better diet, fitness, and lifestyle choices.
- Medications: Your physician may recommend a weight loss medication designed to supplement a healthy eating and exercise routine. You should only trust medications prescribed by a licensed physician and tailored to your particular medical condition.
- Support groups and counseling: Support groups offer counseling to more than one patient at a time, building morale and a sense of community among people sharing a common experience. This therapy can help you find others on a similar path to weight loss without the use of surgical intervention.
Putting It All Together
Medicare covers bariatric surgery for people who meet minimum BMI requirements and may have one or more comorbid conditions related to morbid obesity. You may also receive benefits for weight loss surgery through Medicare Advantage or offset your out-of-pocket costs with a Medigap plan.
Consult your physician to discuss your eligibility for a Medicare-approved gastric banding or gastric bypass and ask your Medicare agent for more information.