Obesity is recognized as a significant health risk, and many insurance companies, including Medicaid and Medicare, are now covering bariatric surgery. Buckeye Health Plan, in collaboration with Medicare and Ohio Medicaid, offers weight loss surgery coverage to eligible individuals. However, coverage can vary, and it's crucial to understand the specifics of your plan. This article breaks down Buckeye Health Plan's policies, eligibility requirements, covered procedures, and alternative options for weight loss.
Understanding Buckeye Health Plan Policies
All policies found in the Buckeye Health Plan Clinical Policy Manual apply to Buckeye Health Plan members. These policies, which may have either a Buckeye Health Plan or a “Centene” heading, guide coverage determinations. Buckeye Health Plan may also delegate utilization management of specific services, and in such cases, the delegated vendor’s guidelines may be used to support medical necessity and other coverage determinations.
Buckeye Health Plan also has a Payment Policy Manual, which contains guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. These policies, which may also have either a Buckeye Health Plan or a “Centene” heading, are used to help identify whether health care services are correctly coded for reimbursement. Buckeye Health Plan may also employ a vendor that applies payment policies to specific services, and in such circumstances, the vendor’s guidelines may be used to determine whether a service has been correctly coded.
It is imperative to directly contact Buckeye Health Plan to verify your specific coverage and benefits.
Eligibility Requirements for Weight Loss Surgery
To be eligible for weight loss surgery coverage through Buckeye Health Plan, candidates generally need to meet specific criteria:
- Body Mass Index (BMI): A BMI of 40 or higher, or a BMI of 35 or above with co-occurring health conditions linked to obesity.
- Co-morbidities: These health conditions can include coronary heart disease, type 2 diabetes mellitus, obstructive sleep apnea, and hypertension.
- Prior Attempts at Medical Weight Management: Evidence of active participation within the last two years in a weight-management program that is supervised either by a physician or a registered dietician for a minimum of three months without significant gaps is typically required. Programs such as Weight Watchers, or weight loss medication alone, may not be considered sufficient documentation.
- Supervised Nutrition and Exercise Program: Participation in a physician or dietitian supervised nutrition and exercise program of at least 3 to 6 months duration within the past 2 years is often necessary.
- Psychological Evaluation: A psychological evaluation by a mental health professional may be required to assess the candidate's readiness for surgery and their ability to adhere to post-operative lifestyle changes.
- Medical Clearance: Medical clearance by a MD or DO is generally required.
Covered Weight Loss Surgery Procedures
Buckeye Health Plan covers a range of weight loss surgery procedures, including:
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- Roux-en-Y gastric bypass
- Sleeve gastrectomy
- Adjustable gastric banding
Prior approval from Buckeye is mandatory for these procedures. The approval process involves submitting a request through a healthcare provider, along with medical records and proof of attempted non-surgical weight loss methods.
The Approval Process
If your insurance carrier covers bariatric surgery, you will need to go through the approval process, which involves meeting specific requirements. Each insurance company has its own set of rules regarding surgical pre-authorization.
Key steps in the approval process:
- Referral: A referral from your primary care physician may be necessary to schedule a consultation with a weight loss surgeon.
- Consultation: Attend a consultation with a bariatric surgeon to discuss your weight loss goals and determine if surgery is the right option for you.
- Evaluation: Undergo a comprehensive medical and psychological evaluation to assess your overall health and readiness for surgery.
- Pre-authorization: Your surgeon's office will submit a request for pre-authorization to Buckeye Health Plan, along with all necessary documentation.
If you are denied, meet the requirements and try again.
Costs and Financial Assistance
The cost of weight loss surgery varies depending on the procedure type, hospital fees, surgeon’s fees, and insurance coverage. Buckeye Health Plan provides financial assistance options for members to make this procedure more accessible. For those patients who are uninsured or do not have weight loss surgery benefits with their current insurance plan, financing options may be available.
Alternative Weight Loss Options
Buckeye also offers alternative weight loss options, like nutritional counseling and support groups, as a starting point for individuals not ready for surgery or seeking additional support. The Ohio State University Health Plan offers additional weight management resources through Your Plan for Health (YP4H).
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GLP-1 Medications and Coverage Changes
The Ohio State University Health Plan has announced changes to its coverage of GLP-1 medications. Starting January 1, 2026, GLP-1 medications will only be covered when prescribed for the treatment of type 2 diabetes; GLP-1 coverage for any other uses will be discontinued. This includes medications like Wegovy (semaglutide), Saxenda (liraglutide) and Zepbound (trizepatide).
Coverage of certain medications used for weight-loss; Wegovy, Zepbound and Saxenda, will continue through December 31, 2025. These medications require participation in Omada, a virtual health program, administered through Express Scripts’ EncircleRx as well as meeting certain coverage requirements. There is a 30-day supply limit for GLP-1 medications used for weight loss.
Maintaining GLP-1 Coverage through 2025:
- Omada Enrollment: If you have not previously done so, you will be required to enroll in Omada.
- Active Engagement in Omada: Active engagement is defined as four weigh-ins and four app engagements per month.
- Prior Authorization: Your provider will need to submit a Prior Authorization request for the desired GLP-1 weight-loss medication to Express Scripts.
If all the requirements are not met, the Plan will not cover any portion of the cost of GLP-1 medications for weight loss.
Omada Program Details
Omada has partnered with Express Scripts, Ohio State’s prescription drug vendor, to provide virtual programs that help provide support for health conditions. The health coaches available to you through their program are experts in weight-loss and obesity disease management, and through the program, you have access to tools and support resources to help manage weight and achieve additional health benefits. Omada can help you build healthy routines around what you like to do and where you need the most support.
Success Stories and Benefits of Weight Loss Surgery
Weight loss surgery can lead to significant weight loss and improved health outcomes. Buckeye’s coverage supports individuals in this transformative journey, providing access to resources and tools for success.
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Ohio Medicaid and Buckeye Health Plan
Ohio Medicaid helps with medical costs for certain people with limited incomes and resources. Ohio Medicaid pays for Medicare premiums for certain people, and pays for Medicare deductibles, coinsurance and copayments. Ohio Medicaid covers long-term care services such as home and community-based “waiver” services and assisted living services and long-term nursing home care. It also covers dental and vision services.
You can choose to get both your Medicare and Ohio Medicaid benefits through Buckeye so all of your services can be coordinated. For Buckeye members enrolled in our Medicare plan, they will get the benefits below from our health plan. For Buckeye members enrolled in our Ohio Medicaid plan, they will get the benefits below from our health plan.
*These services require prior authorization by the health plan - that means we need certain information from you, your provider, or waiver services coordinator to approve the service. If we do not approve a service, we will send you information on how you can appeal our decision and your right to a state hearing. Note: most services get by a provider who is not part of our network require prior authorization by Buckeye.
**Consumers must meet the rules for enrollment into the waiver program within MyCare Ohio. MyCare Ohio will include all of the services that are covered in the following home and community-based Medicaid waivers: PASSPORT, Choices, Assisted Living, Ohio Home Care, and Transitions Carve-out. Contact your Waiver Services Coordinator or Care Manager. 1-866-531-0615.
Healthchek Screenings for Children
Keeping children healthy and growing the way they should is important. A big part of this is seeing the doctor regularly for Healthchek screenings-even when your child is not sick-in order to make sure your child stays healthy. Healthchek screenings help find problems or possible problems early, before they become serious. If a problem is found, Healthchek includes medically necessary follow-up care and referrals. Healthchek screenings are provided from birth to under 21 years of age.