What insurance plans cover bariatric surgery?

Many health insurance plans, including Medicare and most Medicaid plans, cover bariatric surgery. However, health insurance plan coverage varies, so it's important to examine the coverage provided by your plan. Major plans that provide coverage include: Blue Cross/Blue Shield and Priority Health.

What questions should people ask their insurance provider?

1. Is bariatric surgery a covered benefit under my plan?

2. What bariatric surgery procedures are covered?

3. May I have a copy of the Medical Policy statement for bariatric surgery insurance coverage?

4. What criteria do I need to meet in order to be considered for bariatric surgery?

5. Is there a requirement for a medically supervised weight loss program and if so, how long must I be in the program?

6. Do I have a pre-existing clause?

7. What is the co-pay amount, if any?

8. What is the annual deductible, if any, and how much have I met so far?

9. When does my annual deductible renew?*

*Knowing when your deductible renews can help you reduce your out-of-pocket costs. Here's how: Let's say you have already met $875 of your $1,000 annual deductible, and your insurance plan year begins (renews) on August 1. If you have surgery on August 2, you would again be responsible for the $1,000 deductible amount, instead of the remaining $125 from the previous year.

Every year we see a heightened interest in bariatric surgery in November or December because people have met their deductible and want surgery before the new year when their insurance renews. Many don't realize how long the process takes before you get to the operating room. People who are considering weight loss surgery and want to take advantage of the lower insurance deductible should start the process early enough to ensure that they can get surgery by the new calendar year. Note that the process takes about three months from attending an orientation seminar to having surgery. 

Is pre-approval necessary?

Pre-approval is sometimes required for weight loss surgery. It is a way to make sure the procedure is covered under your Bariatric Surgery Insurance policy. Typically, our surgeon's office will submit the required information to your insurance provider to gain pre-approval.

What are some of the most common bariatric insurance coverage requirements?

Some of the most common bariatric insurance coverage requirements include:

• Body mass index (BMI) greater than 40 or BMI greater than 35 with co-morbidities (diabetes, high blood pressure, etc.). To see if you meet these requirements, you can calculate your BMI using our calculator.
• 18 years of age or older.
• Diagnosis of morbid obesity.
• A few insurance plans require participation in a physician-supervised weight loss program for extended time periods (this can vary from 3 to 12 consecutive months, depending on your insurance plan).
• Psychological evaluation prior to surgery. Our bariatric clinic will either provide this service or refer you to a psychologist.
• Documentation of failed diet and exercise plans.

What if my insurance provider denies the coverage?

The surgeon’s office will be notified of the denial of coverage and will assist with you the appeal process if you choose to appeal.

What about Medicare? What does it cover?

Medicare covers all bariatric surgery procedures except the sleeve gastrectomy. Out-of-pocket costs are similar to any other inpatient hospitalization.

Are there payment plan options?

Yes. We partner with a professional financing firm that sets up payment plans. For more information, contact our program.

Are there full cash-pay options?

Yes, cash pay options at Saint Mary’s range from $14,000-$21,000 depending on the type of surgery you choose.

What if I live out-of-town or out-of-state?

We are happy to accommodate patients who come to us from out-of-town or out-of-state. We have a process in place to make it convenient for those who live out-of-town and we will work with you via phone and Internet. We will also partner with your local physician to complete pre-operative and post-operative appointments. Please contact us for specific details.