The vast majority of insurance companies offer policies that cover weight loss surgery; however, the type of policy matters. For example, 23 states require individual and family policies or small group policies offered by companies with fewer than 50 employees to cover bariatric surgery. In contrast, large group policies offered by employers with 50 or more employees only cover weight loss surgery if the company elected to include it in the plan. Medicare and Medicaid both cover bariatric surgery, but some surgeons may not accept Medicaid.
Which States Require Insurance to Cover Weight Loss Surgery?
The Affordable Care Act (ACA) includes bariatric surgery in its essential health benefits (EHB) program. It requires all individual, family, and small group insurance plans to cover bariatric surgery in 23 states, including:
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Rhode Island
- South Dakota
- West Virginia
Three other states include bariatric surgery coverage in some policies. These include:
- Georgia state law requires bariatric surgery coverage for morbid obesity.
- Indiana also has a state law that mandates coverage for morbid obesity.
- Virginia state law requires each state-regulated insurance provider to offer at least one plan that covers bariatric surgery for morbid obesity.
Medicare and Medicaid offer coverage for weight loss surgery but only for Roux-en-Y bypass (gastric bypass) and laparoscopic adjustable gastric banding (LAP band) surgery.
How to Qualify for Weight Loss Surgery Coverage
A policy may offer bariatric surgery coverage, but that doesn’t mean it will pay out for everyone. Most insurance companies require individuals to meet specific requirements before paying for weight loss surgery. These include:
- Body mass index (BMI). Individuals must have a BMI of 40+ or 35+ with an obesity-related comorbidity.
- Proof of medical necessity. Many insurance policies require that individuals show their past unsuccessful attempts at weight loss. Some may require individuals to follow a diet program supervised by their doctor for several months to demonstrate their inability to lose weight before approving the procedure.
- Psychological evaluation. Most insurance policies require a psychological assessment before approving a weight loss procedure. They want to ensure that the individual has realistic expectations, understands the required lifestyle changes, and has a support system to help them achieve and maintain long-term weight loss.
Of the 64 highest market share health insurance providers, 61 have clear pre-authorization policies. Of those 61, all offered coverage for gastric bypass surgery, and 57 provided coverage for LAP band or sleeve gastrectomy (gastric sleeve).
Which of the Largest Insurance Companies Cover Bariatric Surgery?
Seven of the largest insurance companies by market share provide policies that cover bariatric surgery. These include:
- UnitedHealth Group (including UnitedHealthOne and United Healthcare)
- Anthem Blue Cross and/or Blue Shield
- CVS Health (specifically Aetna)
Some exclusions may apply. Always check with your insurance provider to confirm coverage. Your surgeon’s or physician’s office may be able to contact your insurance company on your behalf to verify coverage for weight loss surgery.
Are you ready to begin the next phase of your weight loss journey? Contact Dr. Waldrep to schedule a consultation.