Bariatric Surgery Insurance Coverage

Most healthcare companies cover bariatric procedures. However, weight loss surgery insurance coverage depends on whether there is a bariatric surgery benefit on the specific health care plan. A a general rule – small employer plans (less than 50 employees) will NOT COVER such procedure (“contract exclusion”). Therefore, the plan will not cover the cost of bariatric surgery even if it is medically necessary.

In regards to bariatric surgery health insurance plan coverage we strongly encourage our patients to call their health insurance providers and verify:

• whether your health insurance policy plan covers bariatric surgery (or is it a “contract exclusion”);
• what percentage of the facility and physician’s bill will be patient’s responsibility (copays, co-insurance, deductibles)

Insurance Criteria for Bariatric Surgery

Even though each insurance company has their own written bariatric surgery policy and requirements here are some of the most common criteria:

• BMI over 35 with a comorbidity or BMI over 40
• Letter of Medical Necessity from your primary care doctor
• Nutritional Consult or a series of monthly nutrition consults (up to as many as 6 months)
• Evaluation from a Psychologist and/or Psychiatrist (varies depending on the insurance criteria)
• Documentation of failed medically supervised diet for minimum of two years
• Medical Clearance completed within 30 days prior to surgery

Affordable Care Act

Weight loss surgery guidelines for Affordable Care Act require insurance companies to provide coverage for all individual, family and Small Group plans (plans with 50 or fewer full-time employees) ONLY IN STATES where bariatric surgery can be called an “Essential Health Benefit”.

Essential Health Benefits are determined in each state based on a health insurance plan that legislators find to be the most representative of the “average” plan in the state. Unfortunately, in the state of Florida insurance companies are NOT required to include weight loss surgery through Affordable Healthcare Act. Therefore, if you live in Florida and have health coverage through Affordable Care Act obesity surgery is not covered. Please visit our page and get more information about possibly using a Self Pay option.

Medicare and Medicaid

Medicare covers bariatric surgery as long as all the necessary medical criteria are met and documented. Our Insurance Specialist will go over the list of criteria you need in order to go ahead with the procedure. General information about bariatric surgery coverage on cms.gov.

Straight Medicaid plans unfortunately do not cover bariatric surgery in the state of Florida. However, if you are enrolled in a Humana Medicaid or United Medicaid plan your bariatric procedure will be covered if you meet the required criteria.