UPDATED: OCTOBER 02, 2023 | 3 MIN READ
Weight loss surgery, also known as bariatric surgery, is a life-changing procedure for many individuals seeking to improve their health and quality of life. The demand for these surgeries has surged in recent years, with forecasts indicating significant growth in the bariatric surgery market. However, insurance coverage becomes critical for those considering this transformative journey, with costs averaging between $15,000 and $20,000 or more.
Does insurance cover bariatric surgery?
Bariatric surgery can be financially out of reach for many without health insurance. Fortunately, in the United States, most insurance plans offer coverage for these procedures when specific criteria are met.
According to recent surveys, approximately 95% of insurance companies have a clearly defined pre-authorization policy for bariatric surgery. These policies often cover Roux-en-Y bypass surgery, laparoscopic adjustable gastric banding, or sleeve gastrectomy.
Criteria for insurance approval
Understanding the criteria for insurance approval is crucial for individuals considering bariatric surgery. Insurance companies typically require patients to meet specific qualifications, including:
- A Body Mass Index (BMI) of 40 or higher.
- A BMI of 35 or higher with comorbidities like high blood pressure, diabetes, or sleep apnea.
- Completion of a supervised medical weight management program (MWM) before surgery.
- Documented history of past weight loss attempts.
- Passing a psychological evaluation.
- Smoking cessation.
- No recent evidence of substance abuse.
These criteria often mirror the prerequisites for bariatric surgery, emphasizing the importance of comprehensive health assessments.
Demonstrating medical necessity
To secure insurance coverage, patients must demonstrate the medical necessity of bariatric surgery. This typically involves:
- Meeting the age requirement (usually 18 or older).
- Attaining the required BMI threshold.
- Providing evidence of past weight loss efforts and documented attempts.
- Undergoing a psychological evaluation to assess readiness.
- Committing to smoking cessation and demonstrating no substance abuse.
Realistic expectations and a thorough understanding of the procedure are essential during this process.
States requiring bariatric surgery coverage
Under the Affordable Care Act’s (ACA) Essential Health Benefits (EHB) Benchmark Plans, 23 states mandate that all individual, family, and small group insurance plans cover bariatric surgery. In some states like Georgia, Indiana, and Virginia, specific laws also require coverage for morbid obesity.
Below is a list of states that require insurance to cover bariatric surgery.
- Arizona
- California
- Colorado
- Delaware
- Hawaii
- Illinois
- Iowa
- Maine
- Maryland
- Massachusetts
- Michigan
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Rhode Island
- South Dakota
- Vermont
- West Virginia
- Wyoming
Average cost of bariatric surgery
The National Institute of Diabetes and Digestive and Kidney Diseases reports an average cost ranging from $15,000 to $25,000 for weight loss surgeries. It’s important to note that the expenses vary significantly among different bariatric procedures. For instance, Lap-Band surgery typically incurs different costs than more invasive procedures like gastric bypass surgery.
How much will I pay for bariatric surgery with insurance
Weight loss surgery coverage varies across health insurance plans, so a thorough policy review or consultation with a licensed health insurance agent is essential. If your insurance includes weight loss surgery coverage, qualifying criteria, such as BMI thresholds or specific risk factors like hypertension or diabetes, may apply.
Bariatric surgery costs differ by state, insurer, and plan, necessitating direct discussions with healthcare professionals and your insurer for precise cost details. Your individual plan dictates the total expense, whether it’s a vertical sleeve gastrectomy (VSG) or gastric band surgery.
Different plans offer varying levels of coverage—those with lower deductibles and coinsurance may have higher premiums but ultimately lower out-of-pocket expenses for covered services. Conversely, plans with higher deductibles may feature more affordable premiums but can increase costs for covered medical care.
Streamlining the insurance process
Navigating insurance can be complex, but modern tools and technology can simplify the process. Staying updated on insurance criteria and utilizing digital resources can help streamline approvals and billing, ensuring a smoother experience for patients and healthcare providers.
Insurance coverage for bariatric surgery is within reach for many individuals seeking a path to improved health and quality of life. Understanding the criteria and state-specific mandates is key to navigating this journey successfully.
While the process may seem daunting, patients can access the transformative benefits of weight loss surgery with the right information and resources. We encourage you to take proactive steps, consult with professionals, and embark on this journey toward a healthier and happier life.
FAQs
What types of insurance cover bariatric surgery?
Many insurances include coverage for bariatric surgery. However, there has to be a proven medical need. You must fit certain criteria, and your physician must show that the surgery is medically necessary.
How hard is it to get approved for bariatric surgery?
To qualify for weight-loss surgery, you need to meet these criteria: Possess a body mass index (BMI) of 35 or higher or have a BMI between 30 and 35 while also having an obesity-related condition like heart disease, high blood pressure, diabetes, or severe sleep apnea.
Do most insurances cover gastric bypass surgery?
Insurance coverage varies among providers and policies, but as a general rule, most insurance companies typically offer partial coverage for major bariatric surgeries, including gastric bypass, gastric sleeve, and gastric band procedures.
What is the most affordable bariatric surgery?
The average cost for lap-band surgery, which is generally one of the more affordable bariatric procedures, is approximately $15,000. However, this cost can rise to as much as $30,000, influenced by your geographic location. Conversely, gastric sleeve surgery, considered one of the pricier procedures, typically carries a price tag of around $24,000.
Find insurance that helps pay for bariatric surgery
If you have questions or need guidance on insurance coverage for bariatric surgery, we’re here to help. Contact us at the phone number above or complete our online rate form to compare prices and plan options in your area.
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