Does Medicaid Cover Bariatric Surgery?

Does medicaid cover bariatric surgery? Do they cover gastric sleeve surgery? Is there a co-pay?

Medicaid coverage for weight loss is determined on a state-by-state basis This means that some states cover the procedures while others do not. In terms of requirements for weight loss surgery, Medicaid requires different things compared to other insurance companies. Patients will need to meet several different requirements to qualify for surgery and coverage through Medicaid. They will also need to be free of any medical issue that prevents them or creates a risk for them to have surgery in general. If the patient passes these two tests then Medicaid generally will pay for your weight loss surgery procedure.

Bariatric Surgery Requirements for Medicaid

  • Be over the age of 13 (females) or 15 (male)
  • A body mass index over 35 with one co-morbidity such as high blood pressure, Diabetes, high cholesterol, arthritis, depression, morbid obesity or sleep apnea
  • For patients under the age of 21, a BMI greater than 40 is required as well as one co-morbidity
  • Patients must have a printed letter from their primary care physician recommending them for weight loss surgery to improve one of their conditions or their overall health.
  • All patients must have a mental health exam to show they can adopt the necessary lifestyle changes to succeed.

Provide documentation that they have tried to lose weight in the last year and have failed (Patients must complete a medically-supervised program for six months that is monitored by their physician).

Medicaid will not cover bariatric surgery for individuals with inflammatory bowel disease, chronic pancreatitis, malignant cancer, who are pregnant, other psychological problems or those with long-term use of steroids.

What Bariatric Surgeries Will Medicaid Cover?

When a patient meets the criteria required by Medicaid, they will pay for Lap gastric bands including both Realize Band and Lap Band, gastric sleeve and gastric bypass procedures.

How Much Will Medicare Pay

Generally if they approve the procedure they offer full coverage to the patient. In some instances, other supplement insurance or gap insurance will be needed once the patient has been approved for surgery. This depends on the coverage/plan the patient has and if they have met their deductibles for the year (if applicable). Because these things are so personal to each patient, it is advisable that patients work directly with both their surgeon and Medicaid to understand the costs associated with the surgery and if they will be responsible for any of them prior to having surgery.

Important Things to Know

In order for Medicaid to cover your weight loss surgery, you must have your procedure at a Center for Excellence (unlike Medicare who recently changed their requirements). These facilities have a level of excellence that makes them successful at performing these procedures. If you have any specific questions about your Medicaid coverage and whether or not weight loss surgery is an option for you, contact them directly. Yes your surgeon is a good source of information, but you are responsible for making sure there are no surprises post-op in terms of out of pocket costs and/or overall coverage.