Weight Loss Surgery Foundation of America

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FAQ – Medicare & Medicaid

Does Medicare & Medicaid Cover Weight Loss Surgery?

Medicare & Medicaid
Overview of Medicare

Medicare is a federally funded health insurance program that is available to people age 65 or older or for people under 65 with qualifying disabilities. Morbid obesity is one of the qualifying disabilities under the Social Security Act. Medicare is administered by the Centers for Medicare and Medicaid Services (CMS) which is part of the United States Department of Health and Human Services (HHS). To determine if you qualify for Medicare coverage or want additional information, contact the local social services agency in your area or check out the website for either the CMS (www.cms.hhs.gov) or the HHS (www.hhs.gov).

Overview of Medicaid

Medicaid is a federally funded health insurance program that provides health care and related health-services to qualifying low-income people. The Medicaid program is administered by the Centers for Medicare and Medicaid Services (CMS) which is part of the United States Department of Health and Human Services (HHS). Medicaid eligibility is based on income and other factors such as age, disabilities, citizenship, and other resources. If you want more information or want to see if you qualify for Medicaid, contact the local social services agency in your area or check out the website for either the CMS (www.cms.hhs.gov) or the HHS (www.hhs.gov). Medicaid coverage for Gastric Bypass and lap band surgery is decided on a state by state basis.

Medicare Coverage for Gastric Bypass and Lap Band Surgery

Medicare will cover weight loss surgery surgery for qualified patients when the procedure is performed by approved surgeons and facilities.
This list is at the US Department of health & Human Services web site.

Click Here to see the list of approved facilities
Click Here for a list of State Medicaid web sites
Click Here for a list of contact information for State Medicaide Offices

Medicare coverage and requirements went into effect on February 15, 2006. Like many insurance programs, Medicare patients may have a co-payment amount even if they qualify. Although Medicare pays for weight loss surgery, they do not pre-authorize so it is important to be certain of the requirements for surgery coverage.

Medicare qualified patients are Medicare beneficiaries who have a BMI (body mass index) greater than 35, have at least one co-morbidity related to obesity, have been unsuccessful in losing weight with previous medical treatments for obesity, and lap band surgery is considered a medical necessity. Approval for weight loss surgery is not automatic, but reviewed on a patient by patient basis.

8 Comments

  1. Does medicare cover the excessive skin removal?

  2. Do you have to weigh a certain amount to have the skin removed. I was told that you have to weigh at least 250 pounds. Also what if you don’t have a surgeon to give you a referral. Can it just be your primary doctor that sees that you have excessive skin that needs to be removed.

    • You must be referred by a plastic surgeon. There is no minimum or maximum amount of skin, if your plastic surgeon feels you need the skin removed for medical reasons that is all we require for consideration.
      Antonia

  3. medicare is very discriminating on these procedures. they will cover a gastric bypass and a lap band but not the gastric sleeve. i know i am not the only person who can not have the gastric by[pass or lap band i can only have the sleeve. it is very disciminating !!!!

    • CMS has announced their final decision on whether Medicare will cover the sleeve gastrectomy. Having proposed in April 2012 to only allow coverage of the sleeve as part of a randomized, controlled trial, CMS changed their decision after the final public comment period. CMS announced that they are allowing regional CMS contractors to decide on an individual basis if the sleeve should be covered by Medicare.

  4. FYI…Many facilities accept Medical at differant times. So it’s importamt to verify the facility you are considereing to make sure they still are taking Medical. I work at Fountain Valley Regional Hosptital in Fountain Valley, Ca. In Orange County and we are currently accepting Medical with an IPA. If you’d like more info. Call me 760-519-7911

  5. Aso, regarding Medicare…they have just approved Medicare recipients who qualify, to have Sleeve. FYI

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