Does Insurance Cover Weight Loss Surgery? 8 Key Questions Answered
10 Minutes
Team Curative
Jun 13, 2022
Looking to lose a few pounds? You’re not alone—in fact, you’re in the majority. In 2021, more than half of surveyed Americans were looking to lose weight.
For certain individuals, weight loss surgery may be a practical and effective option for losing weight quickly. However, as with all surgical procedures, costs can get high without insurance.
So, does health insurance cover weight loss surgery? And how much will you have to pay for it if you do or don’t have health insurance?
This page answers key questions surrounding weight loss surgery and insurance coverage so you can feel confident knowing exactly how much you’ll be responsible for paying.
In the future, be sure to work with a transparent and digital-first insurance company that allows you to easily access information about your plan. When you can see the specifics of your plan at a glance, you can spend less time managing your plan and more time accessing the healthcare services you need.
What Are the Criteria to Get Weight Loss Surgery Covered by Insurance?
Does my insurance cover weight loss surgery? As with many healthcare services, the answer is that it depends.
To start, every insurance company is different, meaning there are no rigid standards that every company in the country needs to adhere to. That being said, there are some general guidelines that the majority of insurance companies choose to follow, and in some cases, due to state guidelines, must follow.
In general, to qualify for insurance coverage for weight loss surgery, the following criteria must be met:
You have a body mass index (BMI) of 40 or higher OR you have a BMI of 35 to 40, and you also have a serious or life-threatening health complication related to obesity, such as heart disease or high blood pressure
You have already tried to lose weight through a medically-approved weight loss program and not had success
Curious what your BMI is? The CDC offers a free BMI calculator for adults. Just enter your height and weight and tap “Calculate”.
For more information on BMI in general, visit the CDC.
Which States Require Insurance to Cover Bariatric Surgery?
Weight loss surgeries, generally referred to under the umbrella term bariatric surgeries, make physical changes to your digestive tract to aid in weight loss.
Although not the only one, gastric bypass is a very common type of bariatric surgery where the surgeon creates a small “pouch” and connects it to the small intestines.
Gastric bypass surgery patients are less likely to overeat because the pouch is smaller than the stomach, meaning it gets full—and you feel full—more quickly.
23 states require healthcare plans to cover bariatric surgery: Arizona, California, Colorado, Delaware, Hawaii, Illinois, Iowa, Maine, Maryland, Massachusetts, Michigan, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, and Wyoming.
Georgia, Indiana, and Virginia also require healthcare plans to cover bariatric surgery, but only under certain types of plans.
If you’re looking to lose weight but you’re not sure if you want to make the leap to weight loss surgery quite yet, your state may require insurance companies to offer a less invasive alternative. 16 states require healthcare plans to include some sort of reimbursement for weight loss counseling, and an additional seven states cover nutritional counseling, but only if a diabetes-related diagnosis has been made.
Visit the National Conference of State Legislatures for a full list of which states cover which weight loss-related treatment options.
How Much Does Weight Loss Surgery Cost if You Have Insurance?
Just because you have health insurance doesn’t mean that you will receive coverage for weight loss surgery. Your surgery must be approved by your insurance company first.
Assuming your surgery is approved by your insurance company because it is deemed to be medically necessary, you will likely still have to pay for some portion of your surgery cost. This portion is often dictated by the coinsurance rates you agreed to before you enrolled in your health insurance plan.
An 80/20 split for coinsurance rates is common, which means you would be responsible for paying 20% of the cost of your surgery.
Note that coinsurance rates generally only kick in after you have met your annual deductible. If you haven’t met your deductible, you’ll have to pay the full deductible amount out of pocket. Any remaining costs will be billed on a coinsurance basis between you and your insurance company.
Keep in mind that there may be costs associated with weight loss surgery that are not directly covered by your health insurance plan. For example, if you need to take time off work while you recover from your recent weight loss surgery, that’s a hidden cost that you should account for when determining if weight loss surgery is affordable for you.
How Much Does Weight Loss Surgery Cost if You Don’t Have Insurance?
Without health insurance, you’ll be responsible for the full cost of your weight loss surgery. In general, the cost of weight loss surgery without insurance is between $15,000 and $25,000.
Which Factors Affect the Cost of Weight Loss Surgery?
Costs for weight loss surgery primarily depend on these three factors:
Type of surgery. Some weight loss surgeries are more labor intensive than others and therefore end up costing more.
Your surgeon. In general, surgeons practicing in areas with higher costs of living will charge more for weight loss surgery. Surgeon experience also plays a role in how much they charge.
Location. Hospitals aren’t just for urgent care. The hospital or operating room you choose to have your surgery at will charge a variable price compared to other similar facilities in your area.
How Do You Get Your Insurance Company to Pay for Your Weight Loss Surgery?
The first step is to look into your health insurance plan to see the specific criteria your insurance company requires you to meet before they agree to pay for your surgery.
Next, see if you meet the criteria by assessing different factors about you and your lifestyle, such as your BMI.
If you don’t meet the criteria, consider changing your plan during the next Open Enrollment Period, assuming you are currently using a plan from the federal Marketplace on healthcare.gov or a state-sponsored Marketplace.
From there, seek out a qualified surgeon that is in your approved network of healthcare professionals. Although some types of health insurance plans allow you to see any surgeon you please, most have restrictions on whom you can see if you want to receive coverage.
Finally, ask your surgeon to double-check that everything is acceptable between them and your insurance company. During this step, you should receive an exact list of costs, including what portion you’ll be responsible for.
As you go through the steps, you may be required to visit your primary care physician. For example, you may need to get an official BMI reading, or if you suspect you have a certain condition that has been caused by obesity, you may need an official diagnosis of that condition.
Overall, just like with psychiatry and therapy, it is usually possible to get your health insurance company to pay for the majority of your weight loss surgery treatment.
What if Your Insurance Company Declines Coverage?
If your insurance company declines coverage for your weight loss surgery, you still have options. In fact, you might still be able to receive coverage under your current plan if you take the proper steps.
In many cases, your insurance company will decline coverage simply because you have not proven that your weight loss surgery is a medical necessity. If you can prove that your weight loss surgery is medically necessary, your insurance company may agree to cover your weight loss surgery without any hassles.
The best way to prove medical necessity for weight loss surgery is with the help of your primary care physician. When you go in for an appointment, be clear that you are considering weight loss surgery.
Your primary care physician will ask you questions (similar to during a physical examination), take an official BMI reading, and perform tests to see if you have underlying conditions that were likely caused by your obesity.
In some cases, your insurance company may have declined your request for weight loss surgery coverage because you have not yet tried to lose weight in more traditional ways first, such as through a diet plan. You may need to set up a supervised weight loss program with your primary care physician before any further steps with weight loss surgery can be taken.
If the traditional weight loss plan works for you— that’s great! If it doesn’t, you now have the documentation you need to receive coverage for your weight loss surgery.
Aim to Reduce the Cost of the Procedure Without Insurance
If you can’t get your insurance company to cover your procedure, you can always opt to get the surgery without insurance. Your costs will of course be higher, but with the following methods of reducing costs, you may find it to be more affordable than you thought.
Go to a different location. As covered, areas with high costs of living generally result in higher costs for surgery. If you live in an expensive city, it’s worth exploring your options in suburban or rural areas where the cost of living is generally lower.
Call different surgeons. Different surgeons and offices will bill differently for different types of surgery. If you’re considering a specific type of weight loss surgery, it’s worth getting quotes from a variety of surgeons in your area. Remember, since you’re not using insurance to help pay for the costs, you don’t have to worry about staying in your health insurance plan’s network of approved medical providers.
Call different hospital/operating rooms. A major cost associated with your surgery is where it takes place. Talk with your preferred surgeon to see if they have any recommendations on where to get it done for the best combination of quality and price.
Get a different type of weight loss surgery. Some weight loss surgeries are more affordable than others, but at the same time, not every surgery is right for every patient. Talk with your primary care physician and surgeon to explore more affordable options that can achieve similar results.
If you can’t get the price down low enough to be affordable, consider modifying your health insurance plan for next year so that you can receive coverage for your ideal weight loss surgery.
In many cases, if you know you want this type of surgery, it makes sense to seek out a new health insurance plan with higher monthly premiums and a lower deductible, as you will almost certainly need to pay the entire deductible out of pocket due to the high costs associated with weight loss surgery.
Is Weight Loss Surgery Covered by Medicare or Medicaid?
Do public health insurance plans cover weight loss surgery? Like private health insurance plans, many do, but you are still required to meet certain criteria before you receive approval.
Medicaid requires a letter from your primary care physician stating that weight loss surgery is required and proof that standard treatments (e.g dieting and exercise) were not effective, among other things.
Likewise, Medicare has certain requirements before you can receive approval for weight loss surgery. Head over to the official Medicare website to learn more about weight loss surgery costs under the program.
Conclusion
Does insurance cover weight loss surgery? It depends, but generally, the answer is yes. Almost half of states require their healthcare plans to cover it, and even in states that don’t, you usually have other coverage options to help assist with your weight loss goals.
However, before you receive approval from your health insurance company to undergo weight loss surgery, you will usually have to prove its medical necessity via a BMI reading, documentation stating you tried more traditional avenues first, and correspondence from your primary care physician stating that it is in fact medically necessary.
When it comes to health insurance, the last thing you want to be is in the dark regarding what you’re covered for. In the future, aim to work with a trustworthy and transparent health insurance company that clearly displays everything you’re covered for through an accessible web interface.
