Medicare to Pay for Weight Loss Surgeries? Obesity can exacerbate health problems in older adults. Excess weight increases the risk of diabetes, arthritis, heart failure, and even dementia.
However, in our ‘Weight Loss Surgery Costs’ article, we point out that weight loss surgery candidates can expect to pay $20,000 to $35,000 for their procedure, which is a hefty amount for retired individuals with limited sources of income.
Can You Use Medicare to Pay for Weight Loss Surgeries?
Fortunately, eligible weight loss surgery candidates can seek help from Medicare, the government’s senior-focused health insurance plan, to cover the costs of weight loss treatment.
What does Medicare cover?
Medicare Part B can cover any Medicare-approved weight loss surgery as long as the patient is eligible, which we will cover below. Should the patient choose to recover in a hospital after surgery, Medicare Part A will cover their stay. Patients can also avail of Medicare Part D to get coverage for any necessary prescription drugs.
Weight loss surgery candidates can also sign up for Medicare Advantage, which is a Medicare bundle plan offered by private insurers. Medicare Advantage includes Parts A and B at a lower cost. Depending on the provider, the benefits offered by Medicare Advantage can also cover Part D and post-surgery maintenance costs.
For example, weight loss surgery patients under Medicare Houston receive coverage for drugs and fitness services, as well as access to nutrition experts. These can help them maintain the effects of their procedures.
Which procedures are approved by Medicare?
Medicare only covers gastric bypass, duodenal switch, and gastric banding. Other weight-loss surgeries such as gastric sleeves, gastric balloon surgeries, and intestinal bypass, were not approved by Medicare because there was not enough evidence to prove that these procedures were necessary or safe.
They are a little behind the times as most decent surgeons would refuse to do a gastric band procedure. As more long-term studies have been done, the risks far outweigh the rewards on this one.
The Lap-Band can deteriorate or causes a perforation in the gastrointestinal tract, where acids and fecal matter can leak into the abdomen. Add that to the fact that they tend to break down over time? No one should be considering that as a safe option.
Who is eligible for weight loss coverage?
The Centers for Medicare and Medicaid Services ruled that Medicare can only reimburse weight loss surgery if the patient has a Body Mass Index (BMI) that is greater than or equal to 35 and has had previous unsuccessful medical obesity treatments.
How do you calculate your BMI?
Calculating BMI requires a scale, a measuring rod, and the ability to do simple arithmetic or use a calculator.
You need to know your weight in pounds, and height in inches.
The formula is pretty simple: take your weight number, divide it by your height number. Divide THAT number by your height number (yes – it is done twice). Now, take that number and multiply it by 703, and round to one decimal place.
So I used to be 5’8″ tall, or 68 inches tall. I weighed 358 pounds.
My formula would look like this:
- 358 / 68 / 68 x 703 = ?
- 358 / 68 = 5.26470
- 5.26470 / 68 = .077422
- .077422 x 703 = 54.427768 —
- Round that to one decimal place and my pre-surgery BMI was 54.4!!
So, yeah. I was extremely obese… and am just “overweight” now at 29. I am OK with that and not looking to drop more as I am so freaking active now and reversed any possible comorbidity. I managed to drop it 25.4 points!
I have a lot more muscle mass than I used to and even if I had skin removal surgery for my excess loose skin to drop an estimated 20 more pounds, I would only drop to 27. That is STILL overweight.
Just check out this quick video on BMI thoughts:
Add in comorbidities
Weight loss surgery candidates must also have at least one comorbidity related to obesity — meaning they can only avail of the surgery if their obesity is linked to other health issues, such as type 2 diabetes, high blood pressure, heart disease, or sleep apnea.
Type 2 Diabetes
There are generally two types of diabetes…type 1 and 2…and even though reports show type 2 to be a little milder than type one, it still can cause some serious health conditions.
Based on reports, gastric bypass surgery has shown that it has the ability to eliminate the onset of the disease and rid it from the body. For obese patients, it is more effective and reduces the daily intake of insulin and other medications for up to three years after a successful surgery.
Gastric Bypass and High Blood Pressure
Numerous activities increase your chances of developing high blood pressure, such as having a diet high in salt or cholesterol. Other conditions that may contribute to a high BP are chronic illnesses like diabetes, kidney problems, or hereditary condition.
Having on some extra pounds could also contribute as your body might be lethargic and does not work out too often. After doing the surgery, your diet will be altered to consume less salt and fat-based foods. Also, circulation will improve, and your stress levels might also be improved.
Gastric Bypass and Obstructive Sleep Apnea
Sleep apnea is a common thing for many people, especially those who might be obese or have extra pounds than what their age and height required. Many factors cause the condition, and many people are sometimes required to use a CPAP machine while they sleep.
The idea of having your breathing following an irregular pattern of on and off during sleep can be a serious issue and should be treated to avoid further complications. Gastric bypass helps the body to lose extra weight and improve the other areas of the body.
Research has shown that more than 80 percent of people who do the surgery have had their sleep apnea disappear.
How much will the surgery cost after Medicare?
Individuals enrolled under Medicare are expected to pay deductibles for coverage to take effect. In 2021, the deductible for Part A amounted to $1,484, while the deductible for Part B was at $203.
Under Part B, patients are also expected to contribute a copay equivalent to 20% of the service’s original cost. For example, if the surgery costs $25,000, the patient would still be required to contribute $5,000 on top of their deductibles.
The cost of surgery under Medicare Advantage will vary depending on the chosen provider. It must be noted that Advantage plans are legally required to set a maximum out-of-pocket spending limit less than or equal to $7,550.
What are my other insurance options?
If you’re too young to qualify for Medicare, check whether your state’s Medicaid programs cover weight loss surgery. Medicaid Tenessee, for example, can cover gastric bypass, gastric sleeves, lap gastric bands, and duodenal switch surgery if the patient meets certain requirements. Patients are required to have a psychological evaluation and at least 5 years of documented history proving morbid obesity.
You can also shop for a private health insurance plan. As a result of the Affordable Care Act, 23 states now require insurance plans to include weight loss surgery. Georgia, Indiana, New Jersey, and Virginia also have state laws that mandate morbid obesity coverage.
Medicare is a useful tool for older adults who want to decrease the cost of healthcare expenses. Adults suffering from obesity and attributed health conditions can leverage Medicare to get the most effective recovery options at a reduced cost.
For more information on weight loss surgeries, check out our posts at Gastric Bypass Gal.