Does Fidelis Medicaid Cover Bariatric Surgery


How Can I Get My Weight Loss Surgery Covered

Gastric Bypass Surgery Approval | Medicaid

The criteria for coverage vary with each insurance company. Here at Tri State Bariatrics, we have extensive experience in working with bariatric surgery insurance.

Our dedicated Insurance Liaison specialist will help you understand what is covered under your current health insurance plan, confirm the documents and tests required by your provider, and help you navigate the complex and often confusing paperwork involved.

Your insurance company then reviews all the information submitted and makes a determination. This is commonly referred to as the approval process. The approval process varies among insurance companies. Once formal approval has been received you will be notified.

Blue Cross Blue Shield Federal Bariatric Surgery Requirements 2021

Does Blue Cross Blue Shield cover bariatric surgery for federal employees? The answer is yes, subject to your eligibility for the BCBS federal employees program. At the same time, the state laws related to weight loss surgery insurance coverage will also apply according to the state where you reside and work. Here are some of the key requirements for this coverage.

  • Age and BMI: You must have attained the age of 18 before you can be eligible for Blue Cross Blue Shield federal bariatric surgery coverage. Your BMI should be above 35 along with pre-defined co-morbidities or above 40 with or without obesity-related medical conditions.
  • Obesity diagnosis: To be eligible for coverage under Blue Cross Blue Shield federal weight loss surgery program, you may have to present medical records showing morbid obesity diagnosis for up to three years. Correlating with this, you may submit your PCPs attestation to this effect.
  • Psychological evaluation: An independent, licensed psychiatrist or behavioral specialist may have to carry out a professional psychological before your scheduled bariatric surgery to determine your mental and emotional fitness to undergo the procedure.
  • Possible exclusions: Your Blue Cross Blue Shield federal bariatric surgery coverage may list policy exclusions. These may include experimental procedures, ongoing problem of substance abuse, terminal illness, psychopathology, pregnancy, or history of non-compliance with medical care.

How Is A Person Diagnosed As Overweight Or Obese

The American medical community generally defines obesity and overweight in adults by body mass index, or BMI, a measure of body fat based on height and weight. Its a more sophisticated reading than merely stepping on a scale, but it isnt foolproof. BMI varies by gender, race, body composition, and other factors. If you have a high BMI, generally defined as being in the 25 to 30 range, thats considered overweight. A measure of 30 or more is generally considered obesity.

Elevated BMI by itself may not trigger insurance coverage for services. But once a health condition associated with being overweight or obese such as type 2 diabetes is documented, insurers generally cover care for both the excess weight and the comorbid condition. Thats why it pays to advocate for yourself earlier rather than later.

For people who notice their weight going up or who are having more weight-related health problems, its important to reach out for help, Kahan said. Those who live in rural areas or prefer a remote connection might try a virtual visit with a healthcare provider.

Another option is the CDCs National Diabetes Prevention Program, a lifestyle change and support program for people at risk of type 2 diabetes. Its available online and at various locations around the country. Costs vary but some programs may be free. If you choose one that isnt, check with your insurer or employer to see if its covered. The program is free for eligible people covered by Medicare.

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Find Weight Loss Surgery Financial Help Today

No matter your reasons for considering a procedure, there are many resources to help you meet your goals. Countless individuals have used GoFundMe for medical fundraising to help cover costsbecause the investment in your health and quality of life is well worth it. Tap into the power of medical crowdfunding today so you can live your healthiest life. to start your fundraiser and raise money for your bariatric procedure today.

Does Insurance Cover Weight Loss Surgery

Registered Dietitian Megan Wolf, MS, RD, CDN will privately coach you ...

Making major changes is never simple, and with weight loss surgery, one of the greatest burdens is the cost. For the average individual, bariatric surgery isnt something they can afford to pay for out of pocket.

At the same time, for many people, it is the only solution left to their battle against obesity and an essential tool in ensuring their overall health and wellness. This leads to a brand-new battle: affording weight loss surgery.

Does insurance cover weight loss surgery? Yes and no. Lets dig into the topic to get a better understanding of the relationship between insurance providers and bariatric procedures.

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Top Ways To Get Financial Help For Weight Loss Surgery Costs

If youve ever tried to lose weight, you know how frustrating and difficult the process can be. More and more people are turning to weight loss surgery to help them live healthier lives, but the high price tag still stands in the way for many. If weight loss surgery costs are a barrier for you, learn how you can pay for the medical procedure so you can begin focusing on a healthier future.

State Insurance Law Analysis

We reviewed state laws and regulations for private insurance in both the individual and small-group markets for statutory provisions that expressly prohibit or regulate medical insurers’ medical underwriting or eligibility exclusion practices where obesity or health status is used as an independent risk factor and statutory provisions mandating coverage of obesity-related treatments. The 2004 CMS policy change allowed obesity to be considered a medical condition, and, thus, considered under the term health status.

We conducted a state-by-state document review of state insurance laws and regulations obtained via Internet search of the following websites: each state’s Department of Insurance, National Association of Health Underwriters, Georgetown University Health Policy Institute, National Association of Insurance Commissioners, and legal searches of state insurance codes from Westlaw and Lexis Nexis®. We searched state legislature websites for relevant enrolled legislation that had not yet been compiled into the official state code.

Key words included obesity, weight loss, bariatric surgery, mandated coverage, nutritional counseling, morbid obesity, gastric bypass, underwriting, risk factors for underwriting, exclusions, and preexisting conditions.

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Medicaid Coverage Of Recommended Treatment For Obesity

Forty-five state Medicaid programs cover bariatric surgery with various restrictions. This is consistent with other sources reporting that 44 states covered gastric bypass surgery. We found only 10 states that explicitly covered weight-loss drugs under Medicaid the remaining states were either silent on the issue or excluded weight-loss drugs. This is understandable because under federal law, weight-loss drugs are one of the classes of drugs that Medicaid programs can exclude from coverage. However, our findings differ significantly from previous reports that found anywhere from 17 to 38 states covered at least one weight-loss drug under Medicaid. Most likely, these variations are due to differences in methodologyone report utilized a survey of Medicaid directors, another reported data provided by pharmaceutical companies, and the last did not report the methodology used. We might expect to find fewer states with weight-loss drug coverage from our strict document review.

In contrast, the majority of Medicaid programs will cover bariatric surgery for their enrollees, with restrictions. Surgery is also less likely to be explicitly excluded under Medicaid. Between 1998 and 2002, the number of bariatric surgeries covered by Medicaid increased by more than 260%. During the same time period, surgeries financed by Medicare increased by more than 280%, while those by private insurers increased by more than 480%.

Will My Health Insurance Pay For The Procedure

Medicaid Covers Weight Loss Surgery 2018

Although most insurance companies pay for bariatric surgery if the surgery is medically necessary, many of them also require specific criteria be met before giving approval. Please check with your health care plan to determine whether you meet their criteria. If you do not have insurance and are interested in participating in our self-pay, pre-payment program, please call 319-356-1887 for information.

A growing number of states have passed legislation requiring insurance companies to provide benefits for weight-loss surgery for patients that meet the National Institutes of Health surgical criteria. While insurance coverage for weight-loss surgery is widespread, it often requires a lengthy and complicated approval process. The best chance for obtaining approval for insurance coverage comes from working together with your surgeon and other experts.

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Is Fidelis Part Of The Marketplace

Fidelis Care Qualified Health Plan Products are standardized plans offered by Fidelis Care via NY State of Health, the Official Health Plan Marketplace. Plans fall into various metal levels based on their design and the level of cost sharing required: Platinum, Gold, Silver, Bronze, and Catastrophic Coverage.

What Are The Health Threats Associated With Obesity

The U.S., and the world in general, is experiencing an alarming uptick in overweight and obesity. In 1990, adults with obesity comprised less than 15% of the U.S. population. Today more than two out of three adults in America are overweight, and more than a third of us are obese. The epidemic is not limited to adults, either: 35% of American children aged 2 to 19 have overweight, and nearly 19% have obesity.

This takes a serious toll on our health. People who have obesity, compared with those of healthy weight, are at increased risk for many serious diseases and chronic health conditions. Having overweight or obesity also raises the risk of premature death.

Obesity has been shown to cause or worsen:

  • High blood pressure

The good news is that many of the complications of obesity can be reversed or improved with diet and exercise changes, weight loss, and medical treatment.

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If You Are Covered By Medicare Or Medicaid

Medicare and Medicaid BOTH cover bariatric surgery as long as you meet their qualification guidelines:

To get approved, youll need to be referred by your primary care physician or other attending doctor . Your surgeon will also need to be in The Centers for Medicare and Medicaid Services directory.

Medicaid Coverage & Bariatric Surgeons

Many surgeons do not accept Medicaid due to lower reimbursement levels .

Contact your local surgeon to confirm whether they will accept your Medicaid insurance. If they dont, ask for a referral to a surgeon who does.

If you have Medicare Advantage, youll need to verify that your chosen surgical team and their hospital are in your insurance companys network. Contact your insurance company directly to find out .

See our Medicaid/Medicare Bariatric Surgery page for more information.

How Long Does It Take Medicaid To Approve Weight

Dr. Sarita Dhuper

Medicaid also allows weight-loss surgeries if you meet criteria, but recent studies show approval make take longer.

Insurers usually take a month to approve weight-loss surgeries. However, wait times for Medicaid approval can take five months or more. During that time, Medicaid will review your records and input from your doctor before making the decision.

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Medicaid And Bariatric Surgery

Following bariatric surgery, you may need to make adjustments to your lifestyle, such as dietary changes or limits on specific foods. You may be able to take some drugs to help you adjust to the changes brought on by the operation, at least initially. Medicaid patients are covered for post-operative care and follow-up consultations. To avoid further harm, you must follow the directions of your doctor and the surgical rescue team. Any form of bariatric surgery has the potential for complications. However, with proper care, you should be able to fully recover. Examine the Medicaid Requirements

The patient must fulfill the following conditions to be eligible for weight loss surgery while on Medicaid:

You have a BMI of 35 or above and at least one comorbidity such as hypertension, sleep apnea, high cholesterol, or diabetes.

If you are under the age of 21, you must have a Body Mass Index of greater than 40. You must have at least one of the above-mentioned comorbidities.

The initial step is critical. Your doctor should write you a note suggesting weight reduction surgery as a medical necessity.

They must have a mental health evaluation that indicates their capacity to make the required lifestyle changes for weight loss.

You must show that you are attempting to manage your weight and comorbidities with conventional therapy. You must, however, be able to produce documents proving that you failed.

What Is Gastric Bypass Surgery

Gastric Bypass Surgery Las Cruces has been shown to be effective in helping people lose weight and maintain their weight loss over time. It helps people lose weight by reducing the size of their stomachs. In fact, it is one of the most common types of bariatric surgery.

The surgery involves cutting away part of the stomach and reconnecting it to the small intestine. This creates a smaller stomach pouch that can hold less food, which helps patients feel full after eating fewer calories.

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Whats The Difference Between Medicaid And Medicare

Medicare is a federal program that provides health coverage if you are 65+ or under 65 and have a disability, no matter your income. Medicaid is a state and federal program that provides health coverage if you have a very low income. They will work together to provide you with health coverage and lower your costs.

How Much Of The Surgery Is Covered By Medicaid

Gastric Sleeve. How long did it take medicaid to approve

In most cases, if the surgery is covered by your Medicaid, there will be full coverage available. If there is some part of the surgery that is not covered, you may be able to turn to other supplemental insurance or gap insurance for coverage once you have been approved by Medicaid for the surgery. This could help to push through coverage of any remaining balance with other insurance carriers.

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Which Weight Loss Surgery Is Best

The study found that gastric bypass surgery boasted the greatest weight loss both short- and long-term. But that procedure also had the highest rates of complications in the month following surgery. There are trade-offs. Bypass is more effective for weight loss, but has a greater risk of short-term complications.

What Is Gastric Weight Loss Surgery

Gastric bypass and other weight-loss surgeries known collectively as bariatric surgery involve making changes to your digestive system to help you lose weight. Bariatric surgery is done when diet and exercise havent worked or when you have serious health problems because of your weight.

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During And After Surgery Questions

Are the bariatric procedures done laparoscopically?All bariatric procedures performed at Montefiore Medical Center are done laparoscopically. Laparoscopic surgery, also called minimally invasive surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions.

Will I be put to sleep during my bariatric surgery?Yes, you will receive general anesthesia before your surgery. A breathing tube will be inserted after you are put to sleep to secure your airway in the event of breathing difficulties.

How long will I be in the hospital after bariatric surgery?The time you will be in the hospital varies depending on the type of the procedure you choose and your individual recovery process. Patients who have the gastric band are typically in the hospital only one night, while patients who have the Roux-en-Y gastric bypass or the sleeve gastrectomy may be in the hospital 2 nights or greater.

How long does the bariatric operation take?The actual time of the operation may vary. The gastric band usually takes less than an hour, the sleeve gastrectomy about an hour, and the Roux-en-Y gastric bypass about 2-3 hours. If you have had previous operations the length of your surgery may be longer.

How To Get Medicaid Approval For Weight Loss Surgery

Dr. Sarita Dhuper

If the Medicaid provided by your state covers bariatric surgery, you must consult your physician. Medicaid accepts coverage when there is a medical need for the surgery. It is vital to have a physician who can share relevant information for the medical necessity of bariatric surgery for the patient. Further, to assess the situation, a physician can recommend the patient to approved surgeons.

Approved surgeons help you understand the surgerys basics and different options you may have. After you make a decision, you need to go through some tests and then consult the Medicaid office for pre-approval of the surgery. The process is time-consuming and requires patience as well as perseverance.Before approval, you may have to attend classes to understand the surgery, nutritional requirements, lifestyle changes, and exercises, which are mandatory post the operation. This ensures that the patient understands all implications of the surgery and whats essential to make it successful.

With necessary provisions, you may get approval from Medicaid. These provisions can further include additional classes or further testing. After approval from Medicaid, your surgeon needs to determine your ability to undergo the procedure. This can include medical preparation, blood work, and X-rays. Finally, the surgery is booked. Hence, you get a step closer to a healthier lifestyle and your weight goals.

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How Can A Life

Payment may be denied because there may be a specific exclusion in a patients policy for obesity surgery or “treatment of obesity.” You can appeal such exclusions by submitting a personal written request to the benefits manager within the insureds place of employment and ask for an exception to policy. Insurance payment could also be denied for lack of medical necessity.” A therapy is deemed to be medically necessary when its needed to treat a serious or life-threatening condition. In the case of morbid obesity, alternative treatments such as dieting, exercise, behavior modification and some medications are considered viable and available. Medical necessity denials usually hinge on the insurance company’s request for some form of documentation, such as physician-supervised dieting or a psychiatric evaluation proving that youve tried unsuccessfully to lose weight by other methods.


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