For those struggling with severe obesity, bariatric surgery can be a life-changing solution, but the cost of this procedure may be a challenging barrier to overcome. Understanding your Original Medicare coverage options is crucial if you’re considering seeking bariatric surgery for weight loss. In this article, we’ll walk you through the specific criteria for bariatric surgery coverage under Original Medicare and considerations to keep in mind as you navigate the treatment process.
What is bariatric surgery?
Bariatric surgery is a procedure performed on the stomach and/or intestines to help a person with serious obesity lose weight. This treatment is typically performed when traditional methods for weight loss, like diet and exercise changes, have not been successful. There are several types of bariatric surgery covered by Original Medicare when certain conditions are met, including:
Gastric bypass: Gastric bypass is a type of bariatric surgery that involves creating a small pouch from the stomach and connecting it directly to the small intestine. This procedure reduces the amount of food the stomach can hold and alters the absorption of nutrients, leading to weight loss.
Duodenal switch: A duodenal switch is a type of bariatric surgery that involves reducing the size of the stomach and rerouting the small intestine to limit the amount of food you can eat and digest.
Gastric banding: Gastric banding is a type of bariatric surgery that involves placing an inflatable silicone band around the upper part of the stomach to create a small pouch, restricting the amount of food the stomach can hold.
Sleeve gastrectomy: A sleeve gastrectomy, also called a gastric sleeve surgery, is a weight-loss procedure in which surgeons remove a large portion of the stomach, leaving a smaller, banana-shaped "sleeve."
Vertical gastric banding: Vertical gastric banding (VGB) is a type of bariatric surgery that achieves weight loss only through gastric restriction. This procedure involves stapling the upper part of the stomach, creating a narrow gastric pouch to help limit food intake.
When does Original Medicare cover bariatric surgery?
You may be eligible to qualify for bariatric surgery under Original Medicare according to the National Coverage Determination (NCD) if you:
Have a BMI of 35 or higher
Have tried other medical treatments for obesity without success
Have at least one other obesity-related condition, including diabetes or heart disease
Original Medicare coverage will vary depending on whether the surgery is performed in an inpatient hospital or outpatient center. If you have the procedure at an inpatient hospital, you can use Medicare Part A to help handle the costs, while if you receive bariatric surgery in an outpatient center, you’ll rely on Medicare Part B for coverage. Original Medicare only covers 80% of the cost, which can range from $15,000 to $25,000. Before undergoing bariatric surgery, be sure to discuss costs, coverage, and financial responsibilities with your doctor.
Do Medicare Advantage plans cover bariatric surgery?
Because Medicare Advantage plans must legally cover the same services as Original Medicare, it's important to verify coverage and associated costs with your specific plan, healthcare provider, or facility where the surgery will be performed. Medicare Advantage plans will vary, so be sure to contact your carrier or licensed insurance agent for more information if you’re considering this procedure.
Let SelectQuote Help You Understand Your Medicare Plan Coverage
When you’re considering a procedure like bariatric surgery, it’s important to understand the potential costs and whether you’ll have coverage through your Medicare Plan. Navigating these details can seem overwhelming, but fortunately, SelectQuote can help you understand the complexities of Medicare plans. You can contact us to gain more insights about your existing coverage and get a free comparison of various Medicare Advantage plans.
