Obesity is a serious health problem for people of all ages in the United States. But for elderly people who are overweight, obese, or morbidly obese, the health consequences can be life-threatening. Today in this country, over 35 percent of adults 65 and older (around eight million people) are categorized as obese according to their body mass index (BMI).
Carrying too much weight is not only uncomfortable, but it quite often leads to a host of serious medical complications that can include the following:
- Heart disease
- Hypertension (high blood pressure)
- High cholesterol
- Certain types of cancer
- Excess burden on joints
- Decline in cognitive functions like memory, comprehension, decision making skills, and problem-solving skills
- Loss of quality of life
If you’ve tried to lose weight before and haven’t been successful, having weight loss, or bariatric, surgery may be an option. If you need to lose weight to lower your risks for health complications and lifestyle changes haven’t been effective, your doctor may recommend a weight loss procedure.
How does weight loss surgery work?
Bariatric surgery helps patients by restricting the amount of food they can eat and reducing the number of calories and nutrients the body takes in. There are several different types of weight loss surgery that your health care provider can suggest for you if you are a good candidate. Here’s a look at whether your Medicare coverage can help you pay for these types of procedures.
Medicare covers the following types of weight loss surgery:
- Gastric bypass
- Lap band
- Sleeve gastrectomy
- Duodenal switch
How does Medicare cover weight loss surgery?
Medicare covers some types of weight-loss surgical procedures for beneficiaries who qualify.
To get coverage for bariatric surgery, you must meet the following criteria:
- Your body mass index (BMI) must be 35 or more.
- You have at least one comorbidity such as: high blood pressure, diabetes, sleep apnea, heart disease, etc.
- You have been obese for the past five years and have documented evidence.
- You have documented participation in more than one medically supervised weight loss program which failed.
- Your health care provider certifies in writing his/her support for your weight loss surgery.
- You must pass a psychological evaluation.
- Other possible medical diseases that are treatable have been ruled out as cause for obesity.
If you have Original Medicare Parts A (hospital insurance) and B (medical insurance), the part that covers your weight-loss surgical procedure depends on whether you have the surgery as an outpatient or an inpatient.
Original Medicare Part A covers inpatient procedures when your physician (who accepts Medicare assignment) admits you to a hospital that also accepts Medicare assignment. Part A benefits cover the cost of your surgery, a semi-private room, meals, nursing care, and drugs you need during your inpatient care. However, you must first cover the Part A deductible for the current benefit period.
Original Medicare Part B covers outpatient procedures. If you have your bariatric procedure done in an ambulatory surgical center or a hospital outpatient department that accepts Medicare assignment, your surgery is covered by Part B. In this case, Medicare Part B covers 80 percent of the final approved cost, and you are responsible for the remaining 20 percent after meeting your annual Part B deductible.
How does Medicare Advantage cover weight loss surgery?
If you have a Medicare Advantage (Part C) plan, your insurance provider is required by law to provide at least all the same benefits as Original Medicare Parts A and B. Therefore, if you meet the criteria set by Medicare, your provider must cover your procedure.
However, depending on the type of Part C plan you have, you may need to use physicians, surgeons, hospitals, medical facilities, and medical suppliers that are in your plan’s set network of providers. You may also need to get a referral from your primary care physician to see a specialist.