Who is Eligible for Medicare Coverage of Bariatric Surgery?
To qualify for coverage you must meet the following criteria:
- Have a BMI of 35 or greater
- Have at least one weight-related problem (diabetes, heart disease or sleep apnea
- Documented evidence (in your medical records) of repeated failure to lose weight in medically supervised weight loss programs (diet, exercise programs/counseling or drug therapy)
- Have a psychological evaluation
- All other medical treatments have been ruled out
- The surgery must be performed at a Medicare-approved "Center of Excellence"
- The specific procedure used is approved by Medicare
To get approved, you’ll need to be referred by your primary care physician or other attending doctor (probably not just a self-referral to a bariatric surgeon). In their referral to a bariatric surgeon, your physician should refer to the obesity health problems that are expected to improve after surgery.
If you obtain/have traditional Medicare coverage, you'll need to choose a facility that meets the Centers for Medicare and Medicaid Services’ minimum facility standards and certification requirements for Medicare bariatric surgery.
If you choose/have Medicare Advantage, you'll need to verify that your chosen surgical team and their hospital are in your insurance company's network. Call your insurance company directly to find out.
Regardless of which Medicare plan you have or are applying for, talk with your surgeon to find out if they accept Medicare/Medicare Advantage. They may have some especially useful tips on how to streamline the process with Medicare Advantage insurance companies in your area.
What Will Be My Out-of-pocket Cost With Medicare?
Your out-of pocket costs will depend on which type of plan you receive your Medicare coverage from. If you receive your coverage through:
- Original Medicare Plan: Medicare covers 80% of the approved amount. You are responsible for the remaining amount.
- MediGap/Medicare Supplemental Plan: Call and ask what is covered by the plan. Many times with MediGap plans, you will pay little or nothing.
- Medicare Advantage Plan: Call your plan and ask about costs. The plan must cover at least what Original Medicare does, but it may cover more.
Other important things to know:
- Medicare will not pay for the surgery unless it is completed at a Medicare-approved "Center of Excellence" for bariatric surgery.
- You must have paid your annual deductible for services and supplies before Medicare will begin to pay its share.
- Your costs will be different if you receive your care through one of the Medicare Advantage plans. Call the plan and ask about your share of cost.
- You may pay little or nothing if you are covered by a MediGap/Medicare Supplemental plan. Call the plan and ask about your share of cost.