If you struggle with obesity, weight-loss surgery can help you lose excess pounds that impair your health, mobility and enjoyment of daily activities. People who have bariatric surgery have typically tried to lose weight many times with little or no success, and surgery can be life-changing.
For those considering surgery, one of the first steps is to find out whether your insurance plan covers bariatric procedures. We talked with UNC Health bariatric surgeon Linda Youngwirth, MD, about what questions you should ask.
Does my insurance plan cover bariatric (weight-loss) surgery?
Insurance plans can differ greatly in what they cover and what the requirements are for coverage, Dr. Youngwirth says. Fortunately, most insurance plans have bariatric coverage.
“There is strong evidence that bariatric surgery improves the quantity and quality of life,” she says. “Several studies have looked at the benefits versus the risks of bariatric surgery. Nearly 95 percent of patients report improved quality of life.”
Will you have to pay anything out-of-pocket if you are insured?
Your insurance may not pay for everything, and how much you will owe depends on your insurance plan, including the amount of your deductible. Your insurance may pay 80 percent of the bill, leaving you to pay 20 percent, or you could have a 70/30 plan, or another division of costs. The type of surgery and what part of the country you live in also affect costs. Review these costs carefully with your insurer.
If you have high-deductible health insurance, you may also have a health savings account (HSA) that allows you to put aside money for medical expenses. HSA accounts allow people to put money in accounts pre-tax.
If your health insurance doesn’t cover bariatric surgery, or you need help covering out-of-pocket costs, you could ask your doctor if the hospital or clinic has a financing plan or a lower rate for people who need additional help.
“Many programs, including ours, offer affordable self-pay options,” Dr. Youngwirth says.
What are the qualifying conditions required by my plan?
Most insurance companies set certain criteria for who qualifies for bariatric surgery, including the patient’s body mass index (BMI) and other illnesses (comorbidities) associated with obesity. These comorbidities include type 2 diabetes, obstructive sleep apnea, high blood pressure and abnormally elevated cholesterol in the blood.
The American Society for Metabolic and Bariatric Surgery (ASMBS) recommends bariatric surgery for individuals with a BMI equal to or greater than 30 if they also have an obesity-related condition, or comorbidity. Surgery is recommended for people with a BMI of 35 or more regardless of comorbidities. (A 5-foot-5-inch person would have a BMI of 30 at 180 pounds and a BMI of 35 at 211 pounds.)
These guidelines were updated in October 2022 to be more expansive and include people at lower weights, but “most insurance companies have not adopted the new guidelines and still require a BMI of 40 or greater or a BMI of 35 to 40 with an obesity-related comorbidity,” Dr. Youngwirth says.
Are there age restrictions for bariatric surgery?
There are no minimum or maximum age requirements for bariatric surgery, Dr. Youngwirth says. The American Academy of Pediatrics (AAP) has called for greater access to bariatric surgery for teens who are obese. The AAP reports that 4.5 million children and adolescents in the United States are severely obese and are unlikely to get better by adulthood even with nonsurgical medical care. The AAP says no evidence suggests that “watchful waiting” is effective, and it advocates for insurance companies to cover bariatric surgery for qualifying teens and children.
As for older adults, Medicare provides coverage for bariatric surgery.
What other weight-loss tools does my policy cover?
Policies that cover bariatric surgery also cover visits with doctors and dietitians. Many also cover at least one session with a mental health professional, usually before surgery.
“Most policies will cover visits with a dietitian even if they don’t cover bariatric surgery,” Dr. Youngwirth says.
Exercise is important for losing and maintaining weight, she says. Some plans may cover visits with physical therapists, wellness coaches, gym memberships or exercise classes. These may be covered even if you are not having bariatric surgery.
How can I get help if I’m unsure of what my policy says?
Most clinics that perform bariatric surgery have support personnel in place to help you understand the procedure and check on your insurance coverage. Typically, potential patients must attend an introductory seminar, virtually or in person, to get an overview of everything involved in the procedure and process.
“We have two staff members who are insurance gurus,” Dr. Youngwirth says. “They are here to assist with the process.”
If you are concerned about your weight, talk to your doctor about weight-loss options, or contact Rex Bariatric Specialists.