Original Medicare, Medicare Advantage, and Medigap may all provide coverage for gastric bypass surgery for people who meet certain criteria.
In 2019, more than 256,000 people in the United States had bariatric surgery, also known as weight loss surgery, according to the American Society for Metabolic and Bariatric Surgery.
Several types of bariatric surgery exist, including gastric bypass surgery. In this procedure, a healthcare professional changes the shape of a person’s stomach to help with weight loss.
This article will look at Medicare coverage, eligibility, and costs for gastric bypass surgery.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare covers bariatric surgical procedures, including gastric bypass surgery, when a person has certain health conditions related to obesity.
Medicare criteria for bariatric surgery include:
- having a body mass index (BMI)
greater than 35
- having at least one obesity-related comorbidity
- having tried other unsuccessful medical treatments for obesity
A person with an obesity-related health condition may also qualify for Medicare-subsidized gastric bypass surgery. Such conditions include:
- gallbladder disease
- heart disease
- high cholesterol
- high blood pressure
- sleep apnea
- some types of cancer
- type 2 diabetes
Medicare requirements can vary by state and individual insurance providers. However, people must usually provide the following information to qualify for coverage:
- the results of thyroid, adrenal, and pituitary blood tests, showing all results in a standard range
- the results of a psychological evaluation
- proof of participation in at least one unsuccessful weight loss program that a medical expert supervised
- a doctor’s referral for gastric bypass surgery
Original Medicare (parts A and B) covers the cost of approved gastric bypass surgeries.
After the deductible, Part A covers inpatient gastric bypass surgeries that healthcare professionals perform in hospitals at 100%, while Part B covers outpatient gastric bypass surgeries at 80%, per the Centers for Medicare & Medicaid Services.
Medicare Advantage (Part C) may also cover gastric bypass surgeries. However, a person will need to check that their hospital or medical facility is within their insurer’s network.
Medigap, also known as Medicare supplement plans, may help people with costs not covered by their standard Medicare plan.
In addition, a person could check with their employer to find out if their work insurance covers the surgery. Coverage might also be available through a family member who has a work insurance plan.
The cost of gastric bypass surgery varies by location and service. A person can check with their doctor or hospital for an estimate of the total cost, which can range from
Out-of-pocket costs for gastric bypass surgery may also vary, depending on several factors. These include:
- how much a hospital or medical facility charges
- a person’s Medicare coverage
- whether the person has any other insurance
Whether a person is an inpatient or outpatient for surgery can also affect the costs.
An individual can use this tool to check which parts of Medicare cover the different aspects of their surgery. This allows them to see their potential out-of-pocket expenses.
In general, Part B of original Medicare covers 80% of approved gastric bypass outpatient surgeries. Most people must pay their Medicare Part A and Part B deductibles, plus the Part B 20% coinsurance.
In 2020, the Part A hospital inpatient deductible is $1,484, and the Part B deductible is $203, according to CMS.
The amount that Medicare Advantage plans cover will vary among providers. Generally, people with a Medicare Advantage plan will pay surgery and hospital inpatient stay copays.
A person can use this tool to find more information about a specific plan.
People with Medigap plans can use this coverage for some or all of the expenses associated with gastric bypass surgery.
Medicare may provide coverage for gastric bypass surgery. However, a person must meet certain criteria to qualify.
A doctor can explain the benefits, risks, and costs of gastric bypass surgery to help a person decide whether or not it is right for them.
Most hospitals and medical facilities provide estimates for the cost of gastric bypass surgery and any aftercare expenses.