Does Medicaid Cover Weight Loss Surgery?

Does Medicaid Cover Weight Loss Surgery?

Getting Medicaid to Pay for Weight Loss Surgery

How can you get Medicaid to pay for weight loss surgery? This is becoming an increasingly common question. More and more people are looking to get Medicaid coverage for weight loss surgeries and procedures.

The reality is obesity is a problem in the United States, and it’s known to cause issues such as diabetes, high blood pressure (HBP), and cardiovascular diseases.

This is why Medicaid has committed to cover some weight-loss surgeries, as illustrated below.

What Is Weight Loss Surgery?

Weight loss surgery is a procedure that is done on people who are obese to make them lose weight. Weight loss surgery is used to make changes to your digestive system. See also types of weight loss surgery

What’s The Process of Weight Loss Surgery Approval by Medicaid?

If your state Medicaid covers weight loss surgery, the first step you should take so that you can get approval for surgery is scheduling a meeting with a doctor.

During the meeting, the surgeon will go over the nitty-gritty of the surgery and discuss your possibilities.

Once you have made a decision, the surgeon can run several tests to check your medical health, and if the doctor agrees you’re okay, you can request a surgery pre-approval from the state Medicaid office.

The entire procedure can take quite some time, so you will have to be patient.

If Medicaid approves the operation, the doctor will have to confirm your readiness to undergo surgery at the time.

This could mean checking your blood, some x-rays, and other surgery preparation procedures.

It’s a bit complicated to determine which part of your operation will be covered by Medicaid in your state. But you can confirm with your local state Medicaid office to see whether this information is available for you.

These procedures are by no means cheap, and you might be wondering if you qualify for this procedure.

Read on to find out which bariatric procedures are covered by Medicaid and the criteria used in covering enrollees for weight-loss surgeries.

What are Medicaid’s Criteria for Weight Loss Surgery Coverage?

For Medicaid to pay for your bariatric surgery, you must meet the requirements below

  1. You must be above 13 years for females and 15 years for males.
  2. Your BMI (body mass index) should be over 40 if you’re under 21 years and over 35 if you’re over 21 years.
  3. A letter from your primary care doctor indicating the weight loss surgery is necessary.
  4. A pass in a psychological review.
  5. Proof showing that you have tried to manage comorbidities with normal treatment but with no success. Comorbidities include sleep apnea, HBP, diabetes, and high cholesterol.
  6. Proof showing that you participated in a clinically controlled weight loss program for half a year, and it happened one year before your surgery.
  7. You must confirm that you will change your routine and diet after the weight loss surgery.

What Can Disqualify You From A Medicaid’s Weight Loss Surgery Coverage?

  1. Noncompliance to previous medical treatments.
  2. Conditions such as pregnancy, inflammatory bowel disease, and chronic pancreatitis.
  3. Psychological treatment that could interfere with post-surgery routines and diet.
  4. Cancer.
  5. Long-term steroid usage.

Which Other Medicaid Considerations Are Required?

For Medicaid to pay for your weight loss surgery, it has to be done in a hospital bearing the Bariatric Center for Excellence accreditation. This certification is meant to show you which hospitals have been deemed fit to perform weight loss surgeries by Medicaid.

Medicaid requires that you check in to one of these facilities to warrant that you get the best possible treatment. There are various kinds of operations that you can go through to lose weight, but Medicaid only covers the most common types.

Suppose you need to undergo a different kind of bariatric procedure apart from gastric bypass, gastric sleeve, and lap band revision. In that case, you will need to get a different kind of insurance provider or directly pay out of your pocket for the surgery.

Which Weight Loss Surgeries Does Medicaid Cover?

Gastric Bypass

Gastric bypass is a type of weight loss surgery during which a surgeon operates on your gut and small intestines to make changes to how they digest and absorb food, respectively.

Gastric bypass enables weight loss by:

  • Restricting the amount of food that your gut can hold
  • Limiting the number of nutrients and calories absorbed by your small intestine
  • Transforming your gastrointestinal hormones which help to suppress your appetite and make you fuller for longer

Lap Band Revision

Lap band revision is a bariatric procedure whereby an adjustable silicone band is installed on your stomach to create a small gut section above the band, and the rest of the gut remains below the band. This limits the quantity of food or beverages that you can take in one sitting.

The band is adjustable, and the procedure is reversible. Lap band revision is done laparoscopically, and it’s not as intrusive as other gut procedures.

Gastric Sleeve

Vertical sleeve gastrectomy or gastric sleeve is a type of weight loss surgery that removes about 75% of the stomach. Today this is the most common bariatric procedure done in the United States of America.

Medicaid coverage is not 100%; there are some things you need to pay for, such as

  • Co-payments – This is a fixed sum that you pay when you receive specific checkups. For Medicaid, this normally applies to prescription medicine
  • Deductibles – This is the yearly sum that you pay for a specific timeframe before an insurer starts to cover all your checkups and procedures
  • Co-insurance – This is a chunk of the treatment cost that you have to pay on your own.

Final Thought

Medicaid’s requirements for bariatric procedures or weight loss surgery coverage are a bit different when compared to other insurance providers in the US.

This is because Medicaid is exclusive in who they cover and how they cover these people. As illustrated above, there are quite a several qualifications needed for Medicaid to approve and cover your surgery.

bariatric surgery

See Also

Weight Loss Surgery Grants

Weight Loss Surgery Clinical Trials

Grants for Mommy Makeover

How to get Medicare to Pay for Dental Implants

Lap Band Surgery Cost Without Insurance

Current Version
August 10, 2023
Updated By
Andrea Morales G.

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