Bariatric weight loss surgery is available to people who've failed to lose weight even with a doctor's help - as long as they meet the Medicare guidelines.
As with most major health insurance plans, Medicare covers bariatric weight loss surgery for qualified beneficiaries. In addition to meeting certain conditions, you will have a variety of out-of-pocket costs. On this page, we describe the three types of bariatric weight loss surgery covered by Medicare, your costs, and how to qualify.
What Is Bariatric Weight Loss Surgery?
Bariatric weight loss surgery makes physical changes to your digestive system to help you lose weight. In every case, the patient's stomach is made physically smaller, ensuring you feel more full, more quickly, than you did before the procedure.
Two of the bariatric weight loss procedures covered by Medicare also divert food away from the small intestine. This reduces the number of calories you absorb from food or drink (known as malabsorption).
Which Bariatric Weight Loss Procedures Does Medicare Cover?
Medicare covers three weight loss surgeries:
- Gastric bypass (Roux-en-Y)
- Biliopancreatic diversion with duodenal switch (BPD/DS)
- Gastric banding (LAP-BAND)
The first two bariatric surgery procedures include both making the stomach smaller and malabsorption. You may choose either open surgery or a laparoscopic procedure. The third option is laparoscopic and only reduces stomach size.
What Is Gastric Bypass Surgery?
In gastric bypass, or Roux-en-Y, the surgeon forms a new stomach out of the existing stomach, creating a pouch that only holds around 1 ounce of food or drink. The procedure also involves a duodenal bypass where the new stomach links directly to the small intestine. This creates the malabsorption component for secondary weight loss.
Gastric bypass is one of the more popular weight loss surgery options thanks to its effectiveness. In the first year, patients can expect to lose around 70 percent of their excess weight. However, there are disadvantages. Namely, the procedure is more invasive than LAP-BAND, which means you have a longer recovery time. This is particularly true in the case of open surgery. In addition, the changes made are permanent, and patients typically require nutritional supplements due to the malabsorption aspect.
What Is Biliopancreatic Diversion with Duodenal Switch?
Biliopancreatic diversion with duodenal switch is similar to gastric bypass, in that it creates a smaller stomach and bypasses most of the small intestine. However, instead of creating a small, pouch-like stomach, BPD/DS uses sleeve gastrectomy to remove 80 percent of the stomach. The gastric sleeve leaves a tube-shaped stomach that resembles a banana. The patient gets the same benefits – feeling full more quickly thanks to a smaller stomach and malabsorption of calories. Unfortunately, this also leads to the same nutrition deficiencies seen in gastric bypass. The procedure is extremely effective, although it has more risks than either gastric bypass or LAP-BAND. Typically, your doctor will only recommend BPD/DS if your body mass index (BMI) is over 50.
What Is LAP-BAND Surgery?
Gastric banding, more commonly known as LAP-BAND, involves placing an adjustable gastric band around the upper portion of the stomach. This creates the small stomach pouch you get with gastric bypass, but without removing or permanently altering any part of the stomach.
LAP-BAND also does not include bypassing a portion of the small intestine. It simply regulates the flow of food and drink between the upper and lower stomach, so patients feel full more quickly.
Patients lose weight more slowly after LAP-BAND. However, the band is adjustable, and the procedure is less invasive, meaning there are fewer risks. You can also have the band removed, allowing the stomach to return to its original size and shape.
What Is the Difference Between Open and Laparoscopic Surgery?
Open surgery is the more traditional procedure. In bariatric weight loss surgery, it usually requires an incision between 10" and 12" to allow the surgeon to access the abdomen. In contrast, laparoscopic surgery uses several small incisions (typically less than half an inch). A camera is inserted, allowing the surgical team to view the area on a screen.
Laparoscopic bariatric surgeries are usually considered the better alternative, thanks to their less invasive nature. However, some patients require open bariatric surgery, usually due to an extremely high body mass index.
Who Qualifies for Medicare Bariatric Weight Loss Surgery?
You qualify for Medicare bariatric weight loss surgery if you are enrolled in Medicare and have:
- A BMI of 35 or higher
- At least one obesity-related comorbidity, such as type 2 diabetes or high blood pressure
- A documented history of obesity lasting at least 5 years
You must also have tried – and failed – at least once to lose weight under the guidance of a qualified healthcare provider. In addition, before Medicare approves your bariatric surgery, you must undergo a psychological evaluation and blood tests.
Finally, the Medicare beneficiary's primary care doctor must refer or recommend bariatric weight loss surgery before Medicare will cover the procedure.
How Does Medicare Cover Bariatric Weight Loss Surgery?
How Medicare covers weight loss surgery depends on the type of surgery you get, particularly whether you're an inpatient or outpatient. So, we first need to understand the parts of Medicare.
- Medicare Part A is also known as hospital insurance, because it covers inpatient care received in a hospital or skilled nursing facility (SNF).
- Medicare Part B is also known as medical insurance, because it covers outpatient services like doctor visits, lab work, mental health care, and durable medical equipment (DME).
- Medicare Part C is more commonly known as Medicare Advantage. These are health insurance plans provided by private insurance companies working under guidelines set by the Centers for Medicare & Medicaid Services (CMS). When you join a Medicare Advantage plan, you get your Parts A and B benefits in one policy. In addition, most Advantage plans also provide extra benefits, like prescription drugs and routine vision and dental care.
- Medicare Part D provides prescription drug coverage. As with Part C, private insurance companies sell Part D prescription drug plans. You may get these benefits through a Medicare Advantage Prescription Drug plan (MA-PD) or by joining a standalone Medicare Part D plan.
Original Medicare includes Parts A and B. You may also join a Medicare Supplement Insurance plan, more commonly known as Medigap. These plans help pay some of your out-of-pocket costs when you have Original Medicare. You cannot have both a Medicare Advantage plan and Medigap.
Again, the main question is whether you are an inpatient or an outpatient. If your surgery is as an inpatient, Medicare Part A applies. Beneficiaries who undergo outpatient surgery are covered by Medicare Part B.
If you have a Medicare Advantage plan, please contact your plan provider for details. At a minimum, though, you need to make sure your doctor, surgical team, and hospital are all part of your plan's provider network (if applicable).
How Much Does Medicare Bariatric Surgery Cost?
Your costs will vary depending on a variety of factors, starting with whether you're an inpatient or outpatient and have met your Medicare deductibles. Without insurance, you can expect to pay between $15,000 and $25,000, according to the National Institutes of Health (NIH).
Medicare Part A Costs
Your out-of-pocket costs under Medicare Part A may include monthly premiums, deductibles, and coinsurance. Most people get premium-free Part A, because they or their spouse paid Medicare taxes for the required 10 years (40 quarters) to qualify. Around 1 percent, though, pay the Medicare Part A premium, which is $506 per month in 2023.
The Medicare Part A deductible is $1,600 per benefit period, which begins when you're admitted as an inpatient and ends once you go 60 consecutive days without receiving inpatient care.
Finally, coinsurance under Part A is $0 per day for the first 60 days. After that, you'll pay $400 per day for days 61 through 90 and $800 per day for days 91 through your 60 lifetime reserve days. (Medigap beneficiaries get an additional 365 lifetime reserve days.)
Medicare Part B Costs
Your out-of-pocket costs with Medicare Part B include monthly premiums, coinsurance, and the annual deductible. In 2023, the Part B annual deductible is $226. You must pay this amount out-of-pocket before Medicare begins paying its share.
You also have a monthly premium of $164.90 – even if you join a Medicare Advantage plan. Finally, there is the standard Part B coinsurance of 20 percent of the Medicare-approved cost. So, if your surgery is an outpatient procedure and costs $20,000 (as an example), your co-insurance would be $4,000. That is in addition to any other costs accrued prior to your surgery.
You may also have Part B costs if you have inpatient surgery, as doctor services received while in the hospital still fall under Part B. Outpatient surgery performed in a hospital setting may also have a copayment. It is always a good idea to talk to your healthcare providers to form a better idea of your costs for any procedure.
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