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Fighting Fat: Weight loss surgery insurance Q&A

7:23 AM, Sep 11, 2011   |    comments
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Q&A with Patricia T. Horvath, R.N., M.S.N., executive director of UnitedHealthcare Employer & Individual in Northern Ohio.

Q: Do insurance companies cover weight loss surgeries?
A: Insurance coverage for weight loss surgery varies by state and insurance provider. Many insurance companies - both public and private - now offer coverage, including gastric bypass insurance.

While some insurers may foot the entire bill, many public or private insurance companies that cover weight loss surgery will pay 80 percent of what is considered "customary and usual" for the surgery.

Weight loss surgery is an option for Medicare beneficiaries with a body mass index (BMI) of 35, with at least one health problem related to obesity.

Whether Medicaid covers weight loss surgery varies on a state-by-state basis.

Many private insurance companies will cover weight loss surgery if your primary care doctor informs them that the surgery is medically necessary.

Q: After having weight loss surgery, does that person's health insurance premium decrease?
A: If you are on an individual health insurance plan your premium may be re-evaluated when you renew your plan or apply for a new plan based on your health status. If you are on a group insurance plan such as one through your employer, your premium may not change due to the risk of the collective group. In some instances an employer may have its own incentive program for healthy behavior and you may be rewarded through a premium reduction for good health such as an optimal BMI.

Q: What can people do if their insurance will not cover their weight loss surgery?
A: Collect letters and documentation from all health care professionals who have treated you for health conditions related to obesity. Many insurers also require a nutritional consultation and psychological evaluation.

Someone in your surgeon's office should be able to speak to you about your insurance concerns and questions. Additionally, many bariatric physicians and plastic surgeons offer payment plans. Many practices are also familiar with medical financing companies and can provide information.

If the initial attempt to authorize coverage is denied, you can appeal.

Q: Are kids' weight loss programs -- like one that involves a team of experts working with the child and family-- covered by insurance?
A: Some insurance companies cover medical weight loss for children and adults, some on a limited basis and some none at all. You should check with your insurance company to see if this is a covered benefit.

Q: Does insurance cover the excess skin removal surgery that some people may need after weight loss surgery?
A: Most insurers do not cover body contouring procedures or the costs of diet and fitness plans, behavioral modification therapy and nutritional supplements that follow weight loss surgery.

Q: How does an insurance company approach a request for follow-up surgery if, for example, the weight loss surgery patient has overeaten and stretched the smaller stomach? Would this be covered?
A: These types of rare situations are handled on a case by case basis eliciting the advice of an insurance carrier's in-house medical director in conversation with the patient's physician and assessing the type of coverage the person has at the time the follow-up surgery is needed.

 

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