Unlock the Secrets of CountyCare Coverage for Weight Loss Surgery – What You Need to Know!

Obesity is a growing concern in the United States, affecting a significant portion of the adult and youth populations. Recognizing the serious health risks associated with obesity, many insurance companies, including Medicaid and Medicare, now offer coverage for bariatric surgery. However, coverage varies, and it's crucial to verify your specific benefits.

Obesity: A Growing Epidemic

Obesity in the United States is increasing, affecting 30-36% of the adult population and 17% of youth. The incidence of type 2 diabetes mellitus is also rising, with 81% of new cases occurring in obese individuals (BMI>30) and 49% in those with class II or III obesity (BMI>35). Obesity-related conditions such as stroke, heart disease, type 2 diabetes, and certain types of cancer contribute to the estimated annual medical cost of treatment of obesity in the United States in 2008 of $147 billion.

Obesity increases with advancing age for both sexes in the United States. Racial and ethnic differences are more strongly seen in women than in men. Among non-Hispanic black and Mexican-American men, those with higher incomes are more likely to be obese than those with low incomes. On the other hand higher income women are less likely to be obese than low income women. Among men there is no significant relationship between obesity and education. The converse is true for women in that those with college degrees are less likely to be obese compared to less educated women. Obesity overall is increasing at all income and education levels.

Does CountyCare Cover Weight Loss Surgery?

CountyCare covers medical services along with some additional benefits for its members, generally at no cost. To determine if CountyCare covers weight loss surgery, it's essential to contact Member Services directly at 312-864-8200 / 855-444-1661 (toll-free) / 711 (TDD/TTY).

Insurance Coverage and Requirements

Some insurance carriers do not provide coverage for bariatric surgery. You must call your carrier directly to verify coverage and benefits. If your insurance carrier does cover bariatric surgery, you will need to go through the approval process, which involves meeting specific requirements. If you are denied, meet the requirements and try again. Please note: You MUST call your carrier directly to verify coverage and benefits.

Most insurance companies adhere to national guidelines regarding requirements for weight loss surgery. While specific requirements can vary, common criteria include:

BMI Threshold: A Body Mass Index (BMI) greater than 40, or a BMI greater than 35 with at least one qualifying co-morbidity. BMI must be > 40 or >35 with qualifying co-morbidities for the past year.
Co-morbidities: The presence of obesity-related health conditions such as Coronary Heart Disease, Type 2 Diabetes Mellitus, Obstructive Sleep Apnea, or Hypertension. BMI >40 and secondary health condition or >35 with primary health condition (Coronary Heart Disease, Type 2 Diabetes Mellitus, Obstructive Sleep Apnea, Hypertension).
Prior Weight Management Efforts: Documented failure of medical management, including active participation in a physician or dietitian-supervised weight-management program for a minimum of three to six months within the past two years. Failure of medical management including 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. A program such as Weight Watchers, or weight loss medication alone is not considered sufficient documentation. Six consecutive months of participation in a medically supervised weight loss program within the setting of a pre-surgical multidisciplinary evaluation must be completed within one year before the prior approval request for the bariatric surgery.
Supervised Nutrition and Exercise Program: Participation in physician or dietitian supervised nutrition and exercise program of at least 3 to 6 months duration within the past 2 years.
Psychological Evaluation: A psychological evaluation by a mental health professional to assess readiness for the lifestyle changes required after surgery. Psychological evaluation within 90 days of surgery. Psychological Evaluation. Psychosocial-behavioral evaluation must be completed within 12 months of prior approval request by a licensed psychologist, psychiatrist, clinical social worker, and/or advanced practice nurse in collaboration with co-signing psychiatrist.
Medical Clearance: Medical clearance by a MD or DO. Preoperative medical evaluation.

Some plans may have specific requirements, such as a 12-month medically supervised weight loss program.

Specific Insurance Examples

Here are some examples of BMI requirements for different Blue Cross Blue Shield (BCBS) plans:

Anthem - BMI>40 or BMI>35 with health condition.
BCBS of Illinois - BMI>40 or BMI>35 with health condition.
BCBS of Michigan - BMI>40 or BMI>35 with health condition.
BCBS of Minnesota - BMI>40 or BMI>35 with health condition.
Highmark BCBS - BMI>40 or BMI>35 with health condition.

Additional Considerations for Approval

Beyond the standard requirements, insurance companies may also consider the following:

Demonstration of Participant Responsibility: There is a demonstration of participant responsibility.
Nutritional Assessment and Counseling: Documentation of nutritional assessment and counseling at each visit with at least one visit with a registered dietitian or nutritionist. Dietary history, eating disorder, pre-surgical caloric reduction, dietary behavior modification, and lifelong need for dietary changes must be completed.
Education Regarding Risks and Benefits: Education regarding risks and benefits of bariatric surgery and procedural options.
Language Proficiency: When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient’s lack of proficiency in the English language, an interpreter is required.
Optimization of Health Conditions: Optimization of glycemic control. Treatment of dyslipidemia. Discontinuing estrogen therapy, if applicable. Cardiology consultation and beta-adrenergic blockade, if indicated.
Preoperative Weight Loss: Preoperative weight loss should be considered in patients whom reduction of liver volume is expected to improve the technical aspects of surgery.
Diagnostic Evaluations: Chest radiograph - anterior posterior and lateral. Pulmonary evaluation, including arterial blood gas measurement and polysomnography, if indicated. Smoking cessation; addiction to alcohol and drugs must be addressed. Diagnostic evaluation for deep venous thrombosis and vena cava filter, if indicated. Abdominal ultrasonography and viral hepatitis screen. Institution of CPAP or BiPAP as indicated for obstructive sleep apnea (OSA), obesity-hypoventilation syndrome (OHS), or Pickwickian syndrome.
Cardiovascular and Other Conditions: Coronary artery disease documented by stress testing, previous need for angioplasty, or coronary bypass. Peripheral arterial disease documented by arteriography or Doppler ultrasound of brachial and ankle pressures before and after exercise. Cardiomyopathy documented by echocardiogram or MRI. Pulmonary hypertension by echocardiogram. Carotid artery disease documented by ultrasound with greater than 70% blockage at least unilaterally. Aortic disease documented by CT or MRI. Severe valvular disease documented by echocardiogram.
Medically Refractory Hypertension: Medically refractory hypertension defined as a systolic pressure greater than or equal to 140 and/or a diastolic greater than or equal to 90 obtained by appropriately sized cuff despite treatment with at least 2 antihypertensive medications at maximum tolerable dosages.
Other Obesity-Related Conditions: Nonalcoholic fatty liver disease (NAFLD) / nonalcoholic steatohepatitis (NASH) with submission of liver function panel. Dyslipidemia as defined by hypercholesterolemia greater than 240 mg/dl, hypertriglyceridemia greater than 400 mg/dl, low density lipoprotein greater than 160 mg/dl, or high density lipoprotein greater than 40 mg/dl despite therapy with at least one lipid lowering agent at maximum dosage. Pseudotumor cerebri. Gastroesophageal reflux (GERD). Asthma with severity at least of mild persistent. Lower extremity venous/lymphatic obstructive stasis disease. Severe urinary incontinence. Degenerative osteoarthritis documented radiographically in any weight bearing joint or lumbosacral spine affecting performance of activities of daily living. Uncontrolled type 2 diabetes mellitus. Metabolic syndrome.
Adolescent Patients: Inclusion of a statement detailing at least one custodial parent or legal guardian’s commitment to support and facilitate the adolescent patient’s loss of weight, willingness to support, and facilitate permanent life style changes.

Accessing Weight Loss Surgery with CountyCare

Yes, but a referral from a primary care physician is necessary before you can schedule a consultation with the CWLS.

Navigating the Process

Each insurance company has its own set of rules regarding surgical pre-authorization. To navigate this process effectively:

Contact CountyCare Member Services: Call 312-864-8200 / 855-444-1661 (toll-free) / 711 (TDD/TTY) to inquire about specific coverage details, requirements, and pre-authorization procedures for weight loss surgery.
Consult with Your Primary Care Physician: Obtain a referral from your primary care physician to schedule a consultation with a weight loss surgeon.
Attend a Bariatric Seminar: Consider attending a free informational seminar to learn more about the procedures, the pathway to surgery, and to ask questions.
Schedule a Consultation: Contact a surgeon’s office and complete health and insurance information with a patient advocate. Schedule your first appointment with the surgeon and their team.
Complete Evaluation Period: If both you and the surgeon decide to move forward, start a one to 12-month evaluation period, depending on your insurance.
Final Preparations: After completing all required actions and receiving approval from your insurance company, discuss the final preparations for surgery and schedule a date for the operation with your surgeon.

Finding a Provider

You must receive your care from in-network providers and hospitals. You can find a list of in-network providers and hospitals by using the Find a Provider search tool or you may call Member Services at 312-864-8200 / 855-444-1661 (toll-free) / 711 (TDD/TTY). You must have approval from CountyCare if you go to out-of-network providers. The only exception is for treatment of emergencies, family planning services, school dental services, and state operated hospitals.

Coverage While Traveling

If you travel outside of Illinois and need emergency services, health care providers can treat you. They will send claims to us. You will be responsible for payment of any service you get outside Illinois if the provider will not send claims to us or will not accept our payment. Emergency services are covered only if these services are provided in the United States. Emergency services provided outside of the United States are not covered. For urgent or routine care away from home, you must get approval from CountyCare to go to a different provider. Call Member Services at 312-864-8200 / 855-444-1661 (toll-free) / 711 (TDD/TTY) to get this approval.

Bariatric Surgery Options

Weight loss surgery, also called bariatric surgery, is designed to make the stomach smaller so you feel satisfied with less food. Bariatric surgery might be an option for people with a BMI of 40 or greater or a BMI of 35 or greater, as well as one or more co-morbid conditions, such as high blood pressure, diabetes, sleep apnea or gastroesophageal reflux disease.

There are many different procedures you can have to help with obesity, including:

Read also: Weight Loss Meds & BCBS

Common Bariatric Procedures

Roux-en-Y Gastric Bypass: The Roux-en-Y gastric bypass procedure helps accomplish weight loss by changing how the stomach and small intestine handle food that is eaten. In this procedure, the surgeon creates a small stomach pouch and attaches a section of the small intestine directly to the pouch. This allows food to bypass a portion of the small intestine.
Sleeve Gastrectomy: During the procedure, a thin vertical sleeve of stomach is created (about the size of a banana) using a stapling device. The rest of the stomach is removed. As a result, you will feel fuller sooner and stay fuller longer.
Duodenal Switch: A small gastric sleeve is created, similar to a sleeve gastrectomy, and then an intestinal reconnection is made. This allows food to bypass a portion of the small intestine. You can return home the day after the procedure and resume your day-to-day activities in seven to 10 days.

Minimally Invasive and Robotic Surgery

We are proud to offer minimally invasive and robotic surgery options for your bariatric procedure. Robotic-assisted surgery allows surgeons to perform many different complex procedures, some of which would only be possible using a traditional surgery approach which means larger incisions, longer recovery times, and more potential for wound and other complications. Cook County Health uses the Intuitive Surgical da Vinci® surgical system to perform robotic-assisted surgery. The da Vinci® surgical system has four robotic arms that hold instruments, a camera, and a magnifying screen. Learn More

Revision and Conversion Procedures

We offer revision and conversion bariatric procedures. A revision procedure corrects or modifies the original procedure whereas a conversion procedure replaces it with another type of surgery.

St. David's HealthCare and Bariatric Services

St. David's Bariatric Center has helped many individuals overcome obesity through weight loss surgery. Getting you on track to a healthier lifestyle is our priority. Our comprehensive program is designed to provide you with the highest level of safety and support throughout your weight loss experience. We are committed to providing you with the assistance, encouragement, insight and expertise to help you succeed.

St. David's Medical Center has been accredited by MBSAQIP since 2005. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) works to advance safe, high quality care for bariatric surgical patients through the accreditation of bariatric centers. A center achieves accreditation following a rigorous review process during which it proves that it can maintain certain physical resources, human resources and standards of practice.

The Bariatric Center at St. David's Medical Center is accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). We have also been recognized as a Blue Distinction Center for Bariatric Surgery as designated by Blue Cross Blue Shield, a Bariatric Center of Excellence as designated by Optum Health, a Bariatric Center of Excellence as designated by Cigna and an Institute of Quality for Bariatric Surgery as designated by Aetna.

Are you a candidate for weight loss surgery?

Start your journey today by taking a free assessment.

Weight loss assessment

We offer a short questionnaire to help you determine if you should talk to one of our doctors about weight loss surgery. If you are thinking about weight loss surgery and have doubts about whether it is right for you, you are not alone. It’s a life-changing choice, and serious contemplation is part of the decision-making process. Our team is here to help. Take our weight loss surgery health risk assessment.

Free Medical Information

Free medical information is just a phone call away. Our nurses help you understand your symptoms, treatment options and procedures. They will also help you find a provider or specialist and schedule an appointment.

Other Payment Options

For those patients who are uninsured or do not have weight loss surgery benefits with their current insurance plan, we offer a variety of financing options. If you have questions about our payment options, call us at 877-705-2957, option #4. If you do not have coverage for weight loss surgery, there may be several financing options for you. You have a BMI of 30-35, insurances will not cover your procedure. For more information about the insurance and other options, please call St.

Additional Services at Cook County Health

Cook County Health offers a wide array of surgical specialties, including:

Breast Cancer Surgery: Cook County Health’s Comprehensive Breast Program is dedicated to providing patients with individualized care for breast cancer screening, prevention and treatment. Our experts specialize in breast cancer screening, benign breast disease, genetic testing, breast cancer diagnosis and treatment.
Cardiothoracic Surgery: The Division of Cardiothoracic Surgery treats diseases of the organs within the chest, including the heart and great blood vessels, the lungs, chest wall, glandular tissues and the esophagus.
Colon and Rectal Surgery: The Cook County Health Colon and Rectal Surgery Division provides comprehensive, compassionate and state-of-the-art care for patients suffering from diseases of the colon, rectum, anus and small bowel.
Eye Surgery: The Division of Ophthalmology at the Cook County Health offers medical and surgical eye care to adults and children with diseases and injuries of the eye, orbit and eyelids.
Foot Surgery: Foot doctors, also known as Podiatrists, are physicians and surgeons that specialize in the treatment of conditions affecting the foot and ankle, two of the most complicated parts of the body.
Neurosurgery: The Division of Neurosurgery at Cook County Health specializes in various aspects of adult and pediatric neurosurgery, including Trauma, Oncology, Vascular, Spine (Trauma, Degenerative and complex spinal disorders), and peripheral nerve disorders.
Otolaryngology - Head and Neck Surgery (ENT): The Division of Head and Neck Surgery treats the full array of diseases that affect the head and neck, including cancer.
Pediatric Surgery: The Division of Pediatric Surgery provides general surgery care to children with congenital malformations, trauma and later appearing or acquired conditions that can be corrected with surgical intervention.
Surgical Critical Care: The Surgical Intensive Care Unit (SICU) provides top-quality comprehensive care to patients recovering from major surgical procedures.
Surgical Oncology: Surgical oncology is the branch of surgery which focuses on the surgical management of cancer.
Urologic Surgery: The Division of Urologic Surgery has a distinguished team of surgeons devoted to the diagnosis and treatment of a wide range of complex adult and pediatric urologic conditions.
Vascular Surgery: The Division of Vascular Surgery at the John H. Stroger, Jr., Hospital of Cook County is comprised of four board-certified vascular surgeons.

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