Does Medicare Cover Weight Loss Surgery?

For many individuals struggling with obesity, weight loss surgery also known as bariatric surgery can be a life-changing procedure. Not only can it help with significant weight loss, but it can also improve overall health, reduce the risk of chronic conditions like diabetes, high blood pressure, and sleep apnea, and improve quality of life.
But if you’re on Medicare, one key question might be: Does Medicare cover weight loss surgery? The short answer is yes, but there are some important details and requirements you need to know before moving forward with the procedure.
In this blog, we’ll explore how Medicare covers weight loss surgery, what’s required for coverage, and the types of bariatric surgeries that may be included under your benefits.
Bariatric surgery refers to a group of surgical procedures designed to help individuals lose weight by altering the digestive system. The most common types of weight loss surgery include:
  • Gastric Bypass: A procedure where the stomach is divided into a small upper pouch and a larger lower pouch. The small pouch is then connected to the small intestine to reduce the amount of food that can be absorbed.
  • Gastric Sleeve: A procedure that removes a large portion of the stomach, creating a smaller sleeve that limits the amount of food the stomach can hold.
  • Adjustable Gastric Band: A band is placed around the upper part of the stomach to create a smaller stomach pouch, limiting food intake.
  • Biliopancreatic Diversion with Duodenal Switch: A combination of stomach restriction and malabsorption that alters how food is digested, leading to significant weight loss.
While all of these surgeries are aimed at helping with long-term weight management, only certain types of bariatric surgery are covered by Medicare.

What is Bariatric Surgery?

Does Medicare Cover Weight Loss Surgery?

Medicare Coverage for Weight Loss Surgery

Medicare does cover weight loss surgery, but there are strict criteria that must be met. The coverage is available under Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) for individuals who meet specific health criteria.

Eligibility Criteria for Medicare Coverage of Weight Loss Surgery

To qualify for Medicare coverage for weight loss surgery, you must meet the following criteria:
  1. BMI Requirement: You must have a body mass index (BMI) of 35 or higher. This is considered severe obesity.
  2. Obesity-Related Health Conditions: You must have one or more obesity-related conditions, such as:
    • Type 2 diabetes
    • Sleep apnea
    • Hypertension (high blood pressure)
    • Heart disease
  3. Failed Non-Surgical Weight Loss Attempts: You must have tried other weight loss methods (like diet and exercise) without success. This means you should have documented attempts to lose weight in the past that were unsuccessful.
  4. Doctor’s Recommendation: Your doctor must certify that weight loss surgery is medically necessary for your health and that you’re a suitable candidate for the surgery. Your doctor will also need to provide documentation of your health condition, obesity-related conditions, and history of failed weight loss attempts.

Additional Coverage Requirements

  • Medicare will only cover bariatric surgery if the procedure is performed at a Medicare-approved facility that is certified to provide weight loss surgery.
  • Psychological evaluation Medicare may require a psychological evaluation before surgery to ensure that you are mentally prepared for the challenges and lifestyle changes after the procedure.

What Does Medicare Cover for Weight Loss Surgery?

1. Hospital Stay and Surgery Costs:

Medicare Part A covers the hospital stay associated with weight loss surgery, including:
  • Room and board
  • Anesthesia
  • Surgical procedure
  • Post-surgery care
Medicare Part B may help with the medical services needed before and after surgery, such as consultations, doctor visits, and lab tests.

2. Follow-Up Care and Nutritional Counseling:

After weight loss surgery, nutritional counseling and ongoing care are essential for success. Medicare Part B may cover dietitian services to help with dietary adjustments and ensuring you maintain a healthy weight. However, coverage for follow-up care will depend on the specifics of your Medicare plan.

3. Preventive Services:

Medicare also covers preventive services, which can be beneficial after weight loss surgery, such as:
  • Diabetes management programs
  • Heart disease monitoring
  • Counseling for obesity-related health conditions

What is Not Covered by Medicare?

Although Medicare will cover weight loss surgery under the right conditions, there are some aspects that are not covered:
  • Cosmetic Surgery: If weight loss surgery is being performed primarily for cosmetic purposes (e.g., to improve appearance rather than to improve health), Medicare will not cover the procedure.
  • Non-Certified Centers: If the surgery is performed at a non-certified center, Medicare will not cover the procedure.
  • Weight Loss Drugs: Medicare does not cover prescription weight loss medications as part of its coverage, even if prescribed after surgery.

Final Thoughts: Weight Loss Surgery and Medicare

Medicare’s coverage of weight loss surgery can be a lifesaver for those struggling with severe obesity and related health conditions. If you meet the criteria, Medicare will help cover the cost of the surgery and related medical services. However, it’s essential to meet the eligibility requirements and work with your healthcare provider to ensure that surgery is the best option for your health.
If you’re considering weight loss surgery and you’re on Medicare, talk to your doctor about your options and make sure you meet the necessary criteria. Your Medicare advisor can help guide you through the process and assist you in understanding the costs, coverage, and any additional requirements.

Choosing the Right Medicare Coverage

Selecting the best Medicare coverage depends on factors like your healthcare needs, budget, and preferred providers. You can choose between:
  • Original Medicare (Parts A & B): Allows you to see any doctor or
    hospital that accepts Medicare but does not include prescription drug
    coverage (Part D) or additional benefits.
  • Medicare Advantage (Part C): Offers bundled coverage with
    potential extra benefits but may require using a network of providers.
  • Medigap (Medicare Supplement Insurance): Helps cover
    out-of-pocket costs not covered by Original Medicare, such as
    copayments and deductibles.

Key Medicare Enrollment Periods

It is crucial to enroll in Medicare at the right time to avoid penalties and ensure continuous coverage:
  • Initial Enrollment Period (IEP): A seven-month window starting
    three months before your 65th birthday month.
  • General Enrollment Period (GEP): From January 1 to March 31
    each year for those who missed their IEP.
  • Annual Election Period (AEP): From October 15 to December 7,
    allowing you to switch or enroll in Medicare Advantage and Part D
    plans.
  • Open Enrollment Period(OEP): From January 1 to March 31 for
    those who missed AEP and want to make certain changes.
  • Special Enrollment Period(SEP): Can be used anytime during the
    calendar year for those that meet certain criteria such as moving to a
    new service area.

Finding Help with Medicare

Understanding Medicare can be complex, but you don’t have to do it alone. Licensed Insurance Brokers, Medicare.gov, and state health assistance programs can provide guidance tailored to your specific needs.
By taking the time to explore your Medicare options, you can make informed decisions that ensure you receive the healthcare coverage that best suits your lifestyle and budget.
Do I have to sign up for Medicare?
It depends upon your current coverage. If you are employed and your employer has over 20 employees then you can delay signing up for Medicare and avoid penalties.
No, You will have to enroll in a stand alone Part D plan or a Medicare Advantage Plan(Part C) to get coverage.
There are no networks with Medicare and most doctors and hospitals accept it. However, Medicare does not cover 100% of services so a Medicare Supplement or Medicare Advantage plans is advisable.

Mike Miligi- Owner

For over 10 years, Mike has been assisting Seniors and other Medicare-eligible individuals in understanding the ins and outs of Medicare and Medicare Health Insurance options, including Medicare Advantage Plans(Part C), Medicare Supplement Plans(Medigap), Prescription Drug Plans(PartD), and Dental and Vision programs.
Mike is Licensed in seven States and Certified with 11 Insurance Carriers. He has helped thousands of individuals decide on the best course of action for their particular Health Insurance needs. Because Mike is an Independent Medicare Health Insurance Broker, he works for the client, not the Insurance Carriers, and is able to provide his clients with accurate and unbiased Health Insurance options.
Mike recertifies with CMS(The Centers for Medicare and Medicaid Services) annually, regularly completes Continuing Education Courses required by individual State Insurance Departments, and keeps abreast of industry trends and standards to offer his clients the most up-to-date information.
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