Does Medicare Pay for Bariatric Surgery?
- Medicare covers a few different types of bariatric surgery to help beneficiaries lose weight. Learn more about how much it costs to have bariatric surgery covered by Medicare.
Bariatric surgery includes several different types of procedures performed to help people lose weight. Medicare covers bariatric surgery, but only certain types of surgery and only when your doctor decides it’s medically necessary to treat conditions related to morbid obesity.
Learn more about how Medicare covers different types of bariatric surgeries, and find out how much bariatric surgeries cost with Medicare.
Medicare Covers Gastric Sleeve Surgery and More
The following types of bariatric surgeries may be covered by Medicare:
- Gastric Bypass
- Lap Band or Realize Band
- Duodenal Switch
- Sleeve Gastrectomy
In addition to the procedure itself, Medicare can cover lab tests, medications, durable medical equipment, hospital room and board as well as post-operative checkups.
What Are Medicare Requirements for Bariatric Surgery?
You must meet certain criteria in order for a bariatric surgery to be covered by Medicare:
- You must have a body mass index (BMI) of 35 or more.
- You must have at least one co-morbidity. A co-morbidity is a serious illness that is directly related to your obesity, such as sleep apnea, high blood pressure or diabetes.
- You have documented evidence that your BMI has been at or above the level of obesity for at least the last five years.
- You have a letter from your doctor recommending or supporting the procedure.
- You have passed a psychological evaluation.
- All other treatable medical diseases that could be a possible cause of your obesity have been ruled out.
- Adrenal, pituitary and thyroid tests have been performed and the results have been normal.
- The surgery is performed at a Medicare-approved facility by a doctor who accepts Medicare.
How Much Does Medicare Pay for Weight Loss Surgery?
Bariatric surgery is covered by both Medicare Part A and Part B, the two parts of Medicare that make up Original Medicare. How much you will pay out of pocket for your bariatric surgery will depend on several factors.
1. Which Type of Bariatric Surgery Will You Have?
Gastric bypass is generally the most expensive type of bariatric surgery covered by Medicare.
2. Will You Have Inpatient or Outpatient Surgery?
Bariatric surgeries can be performed at either an inpatient or outpatient facility, and the type of facility — along with your inpatient or outpatient status — can affect the way the procedure is covered by Medicare.
- Medicare Part A covers hospital costs for surgery you get during an inpatient stay at a hospital, including the care from nurses and doctors as well as certain medications. Medicare Part A requires you to meet a deductible of $1,408 per benefit period in 2020 before your coverage kicks in. If your inpatient hospital stay lasts fewer than 60 days, you won’t owe any additional Part A coinsurance costs.
- Medicare Part B covers some of the medical costs associated with your surgery, including doctor’s office appointments, specialist visits, tests, certain medications and durable medical equipment. You’re required to pay an annual Part B deductible of $198 in 2020. After you meet your deductible, you’re typically required to pay a coinsurance cost of 20% of the remaining costs of your surgery.
3. Are You Enrolled in a Medicare Advantage Plan?
If you’re enrolled in a Medicare Advantage (Medicare Part C) plan, your bariatric surgery will also be covered, as Medicare Advantage plans must cover everything covered by Medicare Part A and Part B.
However, your deductibles and coinsurance may differ than those included in Original Medicare. You should check with your Medicare Advantage plan carrier to find out more about how much your surgery might cost.
4. Does Your Doctor Accept Medicare Assignment?
The type of contract that your doctor or facility has with Medicare can affect how much you pay for bariatric surgery.
If your doctor doesn’t accept Medicare assignment, it means they reserve the right to charge up to 15% more than the Medicare-approved amount for their services. These additional costs are called Medicare Part B excess charges. You can easily avoid these charges by making sure that your doctor accepts Medicare assignment before you chose to have your surgery with them.
If you have a Medicare Advantage plan with a network of preferred providers, you should make sure that you get your surgery from a doctor who is in your plan network. You should also make sure your surgery is performed at an in-network hospital. You will typically pay more for bariatric surgery performed by an out-of-network provider, if your plan even covers it at all.
Does Medicare Cover Other Weight Loss Services?
In addition to bariatric surgery, Medicare may provide coverage for some additional weight loss services:
- Diabetes prevention programs
- Foot care for patients with diabetes
- Obesity behavioral therapy
- Obesity and diabetes screenings
- Nutrition therapy and counseling
Some Medicare Advantage plans may also cover memberships to gyms and wellness programs.