Does Private Health Insurance Cover Weight Loss Surgery
- inBlog, Financing, Tax Credit
You may be surprised to learn that public facilities only perform about one-third of all weight loss surgeries in Canada, while private clinics account for the remaining two-thirds. The average wait time for publicly-funded weight loss surgery in Canada is up to 5 years, which can be a long time for patients struggling with weight-related health issues . The types of weight loss procedures offered in public hospitals is also limited. In Ontario, OHIP offers the gastric bypass procedure to most patients who meet their qualifications. Rarely, the gastric sleeve will be offered to a small patient population who suffer from severe scarring or a medical condition that would make a gastric bypass procedure risky.
What Are My Options for Financing Weight Loss Surgery at a Private Clinic?
Many patients ask if their private health insurance will cover some of their weight loss surgery expenses. Most personal insurance plans do not cover weight loss surgery at this point in time. However, if weight loss surgery at a private clinic is the best option for you, there are several financing options available to apply for. You may also quality for a federal medical tax credit for medically necessary procedures. Talk to your financial advisor or accountant to see if you qualify for a medical tax credit.
SmartShape Weight Loss Centre is Canadas Bariatric Centre of Excellence
So How Does Bariatric Surgery Insurance Work
Few years back, bariatric surgery was a standard exclusion across the industry. However, with the changing needs of the world and the technical advancements, bariatric surgery is considered by many insurance companies now. If you are hospitalized for a Bariatric Surgery which is medically necessary, on the advice of a Medical Practitioner, we cover the related medical expenses. However, it is to be kept in mind that Bariatric Surgery Insurance benefit can be availed only when it is medically necessary and not for cosmetic purposes.
How Much Does Gastric Sleeve Surgery Cost
According to one research, it takes an average of three years from the time you contemplate gastric surgery to the time you actually get it. You may spend many hours studying, reading, and speaking with post-operative patients regarding their procedures.
But, how much is gastric sleeve surgery? A Gastric sleeve surgery costs an average of $23,000, while a gastric bypass surgery costs $14,500, and sleeve gastrectomy surgery costs $14,900. So, before you get too excited, find out if your insurance will cover weight reduction surgery or not.
Patients belonging to the middle to upper classes are the majority of people who undergo this surgery. In addition, most people considering weight reduction surgery may not afford to pay the $20,000 gastric sleeve cost to reduce weight.
However, insurance companies are also beginning to pay weight reduction surgery amounts in more significant numbers than ever before. So, if you are determined to get this even after knowing how much is gastric sleeve surgery, talk to your insurance provider.
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Documents Needed To Raise A Claim For Bariatric Surgery
In order to raise a claim for Bariatric Surgery, you may need to produce the following documents to your insurer.
Medical reports indicating a history of suffering from obesity-induced health problems.
Evidence of undergoing dietary and lifestyle changes for the purpose of weight loss.
Proof of unsuccessful attempts at weight loss while undergoing pharmacological therapy .
Should I Pay In Cash Or Use Insurance
When considering getting a bariatric procedure done, insurance is the ideal way to go. However, whether you should pay out of pocket or through insurance will depend on the type of policy you have. Today, most major insurance carriers cover laparoscopic gastric bypass, gastric sleeves, and lap band surgeries. However, that does not mean your health plan also provides coverage for such procedures.
While some plans entirely exclude bariatric surgery, others may require you to pay more to include coverage for weight loss procedures, Read your individual health policy carefully or ask your agent to know whats covered and whats not.
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Health Insurance That Covers Bariatric Surgery
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As per as per WHO guidelines, > 35 BMI is morbid obesity. Bariatric surgery is an operation that helps individuals with obesity to lose weight. A bariatric surgery in India costs anywhere between Rs. 2.5 to Rs5 lakh, and the equipment and technology alone costs around Rs 1.75 lakh.
Tackling obesity may require more than healthy eating and exercise. Bariatric Surgery can be a logical solution in such times.
The good news is health insurers now offer a benefit for Bariatric Surgery, or you can avail Bariatric Surgery Insurance with your health insurance.
Does Bariatric Surgery Insurance Have A Waiting Period
Yes, bariatric surgery in health insurance has a waiting period of usually 2 to 4 years. Which means, if you want to cover your expenses for bariatric surgery you will have to wait for 2 years from the start of your policy. So, it is always advisable to opt for such a benefit with your first health insurance policy itself.
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Find A Weight Loss Surgeon
- You can ask a local bariatric practice for a free insurance check or cost quote
- You can attend a free in-person seminar or an online webinar offered by a local weight loss surgeon
- You should schedule a phone or in-person consultation , if you are interested in learning more about weight loss surgery
Criteria For Coverage Of Surgery Costs
In order for Medicaid to cover the cost of your surgery and the associated surgeon visits, you must meet the requirements below.
- Over the age of 13 for a female and 15 for a male.
- Body Mass Index must be over 35 with at least one comorbidity.
- Co-morbidities include sleep apnea, high blood pressure, high cholesterol, diabetes.
You Might Not Qualify for Weight Loss Surgery Coverage if:
- Long-term steroid use
- Inflammatory bowel disease, chronic pancreatitis, pregnancy, or non-compliance with medical treatment.
- Psychological treatment that might interfere with post-operative compliance with diet and lifestyle.
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Gastric Sleeve Insurance Coverage: What Is Covered
Almost all PPO Insurance companies recognize the necessity of the Gastric Sleeve operation for patients who have been unable to find success using other non-surgical weight loss methods. They understand that as you lose more weight, the less likely it is that you will suffer from other obesity-related conditions, such as type 2 diabetes, hypertension and obstructive sleep apnea.
Gastric sleeve insurance coverage may also even include the post-operation elements that are necessary to be successful with your procedure such as support groups, exercise and nutrition counseling.
Whether or not your coverage is denied, our trained staff of insurance professionals are experts at helping you get your gastric sleeve surgery approved. Just call our Gastric Sleeve Insurance Hotline at or fill out our FREE Gastric Sleeve Insurance Verification Form!
What Are The Conditions That Should Be Kept In Mind To Avail Bariatric Surgery Insurance
To cover the expenses of your bariatric surgery in health insurance, these are the conditions that needs to be kept in mind:
a) The insured person undergoing the surgery is at least 18 years old.
b) BMI more than > =40 or Conditions like morbid obesity with heart disease or diabetes or stroke or disease involving heart and lungs are mostly covered under bariatric surgery.
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Clinical Care Teams Committed To You
When you request an appointment with our program, our clinical care team will gather your insurance information and give your insurance company a call to find out your specific bariatric insurance coverage and benefits.
Your clinical navigator will then provide you with all the information you need to make an informed financial decision, as well as provide you with self pay and financing options if requested.
Where Do I Go For Answers About My Insurance Policy Or Carrier
The customer service number for your insurer will be on your insurance card. You can also visit the insurance companys website, read the most recent insurance handbook from your employer or insurer, or talk to your supervisor or human resources department for questions about your health insurance.
It is important to understand the terms, conditions and limitations of your coverage. If you have questions about your coverage, contact your employers human resources department or your insurance company directly.
For more information on weight loss surgery, click here.
Our accredited program offers a full service, unique weight loss experience. Learn more here.
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Qualifying For Bariatric Surgery:
A person must have a body mass index of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to:
Documentation of all of the following:
**Please Note: All clinical guidelines and qualifying factors vary based on insurance company and the policies in place. If you have specific questions regarding your health insurance policy, please contact our office at , option 2.
The University of California, Los Angeles is designated as:
Most Frequently Encountered Requirements By Insurance Company:
AETNA: Standard NIH weight criteria, 5 years documented by a doctor history of obesity, supervised 6-month diet within 2 past years, evaluation by dietitian & psychologist.
Blue Cross/Blue Shield: Standard NIH weight criteria, supervised 6-month diet within 2 past years, evaluation by dietitian & psychologist.
Blue Cross Federal: Standard NIH weight criteria, 3-6 months supervised diet, evaluation by dietitian & psychologist.
CIGNA: Standard NIH weight criteria, supervised 6-month diet within 2 past years, evaluation by dietitian & psychologist.
United/MAMSI/MDIPA/Optimum Choice: Standard NIH weight criteria, 5-year weight history, evaluation by dietitian & psychologist. Some plans may require 6 months supervised diet.
United/MAMSI/MDIPA/Optimum Choice Federal: Standard NIH weight criteria, supervised 6-month diet within past 2 years, evaluation by dietitian and psychologist.
Medicare/Medicaid: Standard NIH weight criteria, supervised 6-month diet, evaluation by dietitian and psychologist, participation in preparation/conditioning program with surgeon for 3 months. Eligible co-morbidities include hypertension untreatable with 2 or more medications, type II diabetes, obstructive sleep apnea, severe arthritis requiring joint replacement, or fatty liver. Weight loss of 10 percent or more before surgery makes patient ineligible for surgery, and revision procedures are not covered unless there is a complication of initial surgery.
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Whats Covered In Insurance
If you are lucky to have an insurance plan that covers bariatric procedures, then it is likely youd want to know whats covered in the policy. This may vary depending on your policy type, insurance company, or how much you pay for the coverage. Typically, a health plan will protect your finances by providing a wide range of benefits that include:
- Cashless hospitalization at any network bariatric center or hospital
- Daily allowances
- Coverage for pre-and post-hospitalization medical expenses
- Alternative treatment if required
- Ambulance cover
- No claim bonus
However, there are certain eligibility criteria that you must fulfill to get coverage for your bariatric surgery. Most insurance companies need the individuals to meet the following conditions:
- The insured must be 18 years old or above
- The bariatric procedure is prescribed by the doctor
- BMI of the insured is more than or equal to 40
- Or the BMI is greater than or equal to 35, but the individual has severe comorbidities like coronary heart disease, sleep apnea, cardiomyopathy, or Type 2 diabetes that require less invasive weight loss methods
Weight Loss Surgery Insurance Secrets
When you have made the big decision to achieve permanent freedom from obesity, nothing should come in your way to qualify for weight loss surgery insurance. However, in reality, many patients experience challenges in getting approvals or face claim denials from their insurers. Here are five proven weight loss surgery insurance secrets that will help you obtain approval for maximum coverage from your insurance company.
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What Is A Letter Of Pre
A letter of pre-determination or pre-certification from your insurance company means their medical review department has decided, based on the information provided, that your surgery is medically necessary. But this does not mean they will cover your surgery. That depends on your individual insurance policy.
We will submit the necessary documentation to your insurance company. Please do not ask any other physician to submit anything directly to your insurance company. They can provide necessary documentation to us, and we will submit everything as the insurance company requires.
Complete List Of Insurance Companies & Bariatric Policies
The table below lists ALL health insurance companies in the United States along with the following:
- Link to bariatric surgery insurance coverage policy: the presence a link to your insurance companys policy does NOT confirm whether or not you have coverage.
- Link to insurance company contact info: Weve found your insurance companys contact info for you so you dont have to go digging for it.
Ask Your Surgeon for a Free Insurance Check: Most surgeons will contact your insurance company for you for free to confirm your bariatric surgery insurance coverage.
to contact a local surgeon to ask for your free insurance check.
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Can Anyone Get Weight Loss Surgery
No, it’s not always possible for anyone to get weight loss surgery. This is because it’s not always the best course of action for everyone. It also depends on whether you receive treatment through the public system or privately.
To be eligible for treatment in the public system , you need to have a body mass index of at least 35, demonstrate that you’ve failed using other approaches and you’ll have to undergo a psychological evaluation. You’ll also have to find a public hospital that will do this sort of treatment, of which there are only a few in Australia.
Private health insurers will require you to have a face-to-face consultation with a physician to determine if the surgery is necessary and some insurers require you to have a BMI above a specific number. However, these requirements are less restrictive than Medicare and you will have more choice of hospitals.
What Will My Out Of Pocket Expenses Be
Exact coverage for surgery will vary based on your benefits. We encourage patients to call BCBS Florida Blue directly using the phone number on the back of your insurance card or speak to your HR department for policies through your employer. During your office consultation, our Bariatric Coordinator will spend time with you to review your specific benefits and obligations, including what may be required for coverage.
Many plans have deductibles, co-insurances and out of pocket maximums that reset with the calendar year each January 1st. If you are approaching the end of the year, your actual out of pocket expenses for surgery may be lower if you have already paid for medical treatment earlier in the year. Please keep in mind, there may be several required visits prior to surgery being scheduled and it is best to plan several months in advance, even if you plan to take advantage of a paid deductible or met out-of-pocket max for bariatric surgery.
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The Use Of Health Insurance For Bariatric Surgery
With the high costs associated with Bariatric Surgery, it may lead to the question of using health insurance to cover the cost Either partially or completely.
While this will change based on each individual health insurance company and coverage, there are usually base requirements to qualify for insured coverage of the procedures.
Most insurance companies may require:
- Proof that the surgery is medically necessary
- Previous participation in physician-supervised diet & weight loss programs
- A psychological & nutritional evaluation
If you meet the above requirements, the surgeon can provide your insurance company with a pre-authorization document outlining the necessity of the surgery. Once done, its up to the insurance company to review the case and decide the next steps, whether that be to cover the cost of the surgery, or provide other solutions.
Does Anthem Blue Cross Georgia Cover Bariatric Surgery
One of the first questions that our Georgia patients ask is whether their insurance will cover bariatric surgery and if so, what will their out-of-pocket expense be?
Anthem Blue Cross Georgia is the largest health insurer in the state with over 1,000,000 policies and over 30% market share. As a result, Blue Cross is often at the forefront of insurance company policy changes as they relate to coverage of bariatric surgery and other procedures.
The most important thing to understand about any health insurance policy is that beyond the list of covered procedures, there are also specific exclusions. Bariatric surgery is a common exclusion and a read through your policy documents and calling Anthem Blue Cross Georgia can give you clarity on your specific policy. We can also assist you in verifying your benefits, but it is important that you speak to your insurance to clarify any questions you may have.
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