February 2nd 2024
By Ari Parker
Learn about how Medicare covers weight loss surgery, like gastric bypass surgery and laparoscopic banding surgery, for people who are affected by obesity.
The weight loss journey can be frustrating, and people over the age of 60 experience unique challenges with managing their weight. Being overweight is also linked to other health conditions like cardiovascular disease and diabetes. Many people need weight loss surgery to combat these issues and improve their quality of life.
Although eligibility requirements are strict, Medicare does cover weight loss surgery for people who are considered obese. In this post, we’ll explain what kinds of weight loss surgery Medicare covers, what criteria you’ll have to meet, and other Medicare-covered services for weight management.
Medicare covers weight loss surgery, like gastric bypass surgery and laparoscopic banding surgery, for people who are affected by obesity.
To be eligible for Medicare coverage, a person needs to meet the following criteria:
Have a body mass index (BMI) of more than 35
Have an obesity-related condition
Have tried other weight loss alternatives that haven’t been successful
Show a commitment to changing diet and exercise habits
Weight loss surgery, also called bariatric surgery, helps people who are obese lose weight. There are different kinds of weight loss surgery depending on what you need and your healthcare considerations.
Gastric bypass surgery is the most common type of weight loss surgery. In this procedure, surgeons create a small stomach pouch that connects to the small intestine to reduce the amount of food the stomach can hold. This procedure also reduces the absorption of nutrients.
This surgery involves removing a large portion of the stomach and creating a smaller stomach to restrict the amount of food that can be consumed.
This is a less surgically-intensive procedure where a saline-filled balloon is placed in the stomach to limit how much it can hold. This makes you feel fuller and encourages weight loss. A medical professional typically takes out the balloon after a few months.
Laparoscopic banding surgery is another common weight loss surgery. It involves placing an adjustable band around the upper part of the stomach, which creates a small pouch and a smaller passage into the larger area of the stomach. The band is filled with saline so you can adjust the size and control how much food the stomach can hold.
Medicare only covers some types of weight loss surgery, like gastric bypass and laparoscopic banding surgery. To get Medicare coverage for weight loss surgery, you’ll also need to meet strict eligibility requirements. This can make the process more difficult and limit your potential for coverage.
It’s important to stay aligned with your healthcare provider about the best options for your weight loss needs. Based on what they recommend, you could consider other alternatives for weight loss if Medicare doesn’t cover the weight loss surgery you need.
It’s also helpful to know that Medicare doesn’t cover cosmetic surgery, like liposuction, or weight loss medication, like Wegovy.
It’s difficult to assess exactly how much you’d have to pay with surgery since everyone has different healthcare needs before and after the procedure. You can get a rough estimate of costs, but the best way to know for sure is to talk to your healthcare provider and insurance provider before receiving treatment.
With Original Medicare, Part A helps pay for the surgery if it occurs in an inpatient setting and Part B helps pay for surgeries that occur in an outpatient setting. Like with other services, Part B only pays for 80% of covered procedures after you meet your Part B deductible. You’re responsible for the other 20%—this is your coinsurance. If you have a Medicare Supplement plan, it will reduce your out-of-pocket costs, based on your specific plan’s coverage.
Medicare Advantage plans cover the same services that Original Medicare does, but out-of-pocket expenses and deductibles can vary between plans. It’s best to contact your health insurance provider for an estimate of charges if you’re eligible for weight loss surgery. You may also need to get prior authorization.
A Medicare Part D prescription drug plan will help cover medications for recovery and maintenance following the surgery. The list of drugs that your policy covers can vary between plans. Check to make sure that whatever your healthcare provider prescribes to you is covered by your drug plan.
There are a few qualifications you’d have to meet before Medicare can cover any weight loss procedure:
You need a body mass index (BMI) of more than 35.
You must have an obesity-related health condition like diabetes, heart disease, or hypertension.
You need to have tried other alternatives for weight loss that haven’t been successful.
You need to show a commitment to long-term lifestyle changes like a steady diet and regular exercise.
Losing weight can be really hard—it takes a lot of determination and kindness toward yourself. If you’re seeking other alternatives for weight loss, Medicare can provide coverage for:
Nutrition counseling for diabetes-related concerns
Weight loss counseling if you have a BMI of more than 30
Both nutrition counseling and weight loss involve regular check ups with an expert, screenings, and a lifestyle plan to meet your weight loss goals.
Working with your healthcare and insurance provider can ensure that you get the best care and coverage for weight loss. If you have any other questions about what Medicare can pay for when it comes to weight loss services, talk to one of our licensed Advisors who can walk you through all of your benefits. Call 855-900-2427 or schedule a time for free, personalized advice.
