Obesity is a growing concern in the United States, affecting a significant portion of the adult and youth populations. Weight loss surgery can be a transformative solution for individuals struggling with obesity and related health conditions. Home State Health, a Medicaid managed care plan in Missouri, offers coverage for this potentially life-changing procedure. This article delves into Home State Health's weight loss surgery coverage, outlining eligibility criteria, covered procedures, and the process of accessing this benefit.
Understanding Home State Health
Home State Health provides affordable health coverage for various populations in Missouri, including children, pregnant women, and families, at no cost to members. It also serves as Missouri’s dedicated Medicaid managed care health plan for children and youth in foster care, former foster care, adoption subsidy, and select juvenile justice programs. Home State Health's plan in the Health Insurance Marketplace is called Ambetter, offering affordable healthcare coverage for individuals and families.
Health plan benefits give you access to the care you need to keep you healthy. Benefits like dental screenings allow eligible members to enjoy regular dental visits because preventive care is key to good oral health. Home State Health also promotes preventive care through programs like "Shoes for Shots," which encourages children and teenagers to get their HPV shot, a vital vaccine against diseases known to cause certain cancers later in life.
Eligibility Criteria for Weight Loss Surgery
To qualify for weight loss surgery under Home State Health, individuals must meet specific criteria, including:
- Body Mass Index (BMI): A BMI of 40 or higher, or a BMI of 35 or higher with obesity-related health conditions.
- Unsuccessful Non-Surgical Weight Loss: A documented history of unsuccessful attempts at non-surgical weight loss methods, such as diet and exercise.
- Commitment to Lifestyle Changes: A willingness to commit to a healthy lifestyle after surgery.
Covered Weight Loss Procedures
Home State Health covers two main types of weight loss surgery:
Read also: Benefits of couples massage detailed
Restrictive Procedures: These surgeries reduce the size of the stomach, limiting the amount of food that can be consumed. Examples include:
- Gastric banding
- Sleeve gastrectomy
Malabsorptive Procedures: These surgeries alter the digestive system, reducing the body’s ability to absorb calories and nutrients. Examples include:
- Gastric bypass
- Duodenal switch
Accessing Weight Loss Surgery Through Home State Health
To access weight loss surgery through Home State Health, individuals must undergo a thorough evaluation process:
- Consultation with a Weight Loss Surgeon
- Medical Evaluations: Assessments to determine overall health and suitability for surgery.
- Pre-operative Counseling: Preparation for the surgery and required lifestyle changes.
Once the pre-authorization request is approved, Home State Health collaborates with patients to create individualized treatment plans, which may include:
- Counseling to support emotional and behavioral changes.
- Nutrition guidance to optimize dietary choices, including dietary history, eating disorder assessment, pre-surgical caloric reduction, dietary behavior modification, and understanding the lifelong need for dietary changes. Documentation of nutritional assessment and counseling at each visit with at least one visit with a registered dietitian or nutritionist.
- Support groups to provide ongoing encouragement and motivation.
The Growing Problem of Obesity
Obesity in the United States is a significant public health issue, with prevalence rates increasing among both adults and youth. Specifically, 30-36% of the adult population and 17% of youth are affected by obesity. The problem tends to worsen with age and exhibits racial and ethnic disparities, particularly among women. Higher-income non-Hispanic Black and Mexican-American men are more prone to obesity, while higher-income women are less likely to be obese. Education levels also play a role, with women holding college degrees being less likely to be obese compared to less educated women.
Read also: How digestive health affects weight loss
The rise in obesity rates is closely linked to an increase in obesity-related conditions, such as stroke, heart disease, type 2 diabetes, and certain types of cancer (esophagus, breast -postmenopausal, endometrium, colon and rectum, kidney, pancreas, thyroid, and gallbladder). Notably, 81% of new diabetes cases occur in obese individuals (BMI>30), and 49% in those with class II or III obesity (BMI>35). The medical costs associated with treating obesity in the United States were estimated at $147 billion in 2008, underscoring the economic burden of this health issue.
Benefits of Weight Loss Surgery
Weight loss surgery offers many potential benefits for individuals struggling with obesity:
- Significant weight loss.
- Reduced risk of obesity-related health conditions such as diabetes, heart disease, and sleep apnea.
- Improved mobility and energy levels.
- Enhanced self-esteem and body image.
Additional Considerations for Bariatric Surgery
Several preoperative requirements and considerations are essential for individuals considering bariatric surgery:
- Medically Supervised Weight Loss Program: 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.
- Demonstration of Participant Responsibility.
- Psychosocial-Behavioral Evaluation: 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.
- Education: Comprehensive education regarding risks and benefits of bariatric surgery and procedural options.
- Language Interpretation: 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: This includes glycemic control, treatment of dyslipidemia, and discontinuing estrogen therapy if applicable.
- Cardiology Consultation: Cardiology consultation and beta-adrenergic blockade, if indicated.
- 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, pulmonary evaluation, smoking cessation, diagnostic evaluation for deep venous thrombosis, abdominal ultrasonography, and viral hepatitis screen.
- CPAP or BiPAP: Institution of CPAP or BiPAP as indicated for obstructive sleep apnea (OSA), obesity-hypoventilation syndrome (OHS), or Pickwickian syndrome.
Specific medical conditions require careful documentation and management:
- Coronary artery disease.
- Peripheral arterial disease.
- Cardiomyopathy.
- Pulmonary hypertension.
- Carotid artery disease.
- Aortic disease.
- Severe valvular disease.
- Medically refractory hypertension.
- Nonalcoholic fatty liver disease (NAFLD) / nonalcoholic steatohepatitis (NASH) with submission of liver function panel.
- Dyslipidemia.
- Pseudotumor cerebri.
- Gastroesophageal reflux (GERD).
- Asthma.
- Lower extremity venous/lymphatic obstructive stasis disease.
- Severe urinary incontinence.
- Degenerative osteoarthritis.
- Uncontrolled type 2 diabetes mellitus.
- Metabolic syndrome.
For 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.
Read also: Weight Loss Meds & BCBS
Medicare Coverage for Bariatric Surgery
Both Original Medicare and Medicare Advantage plans cover some bariatric surgeries if they are medically necessary. Part D prescription drug plans may cover postsurgery medications needed for recovery.
Medicare covers some bariatric surgical procedures, such as gastric bypass surgery, when individuals have specific health conditions related to obesity.
People must meet certain eligibility requirements for Medicare to cover the costs.
- have a body mass index (BMI) greater than 35
- have at least one obesity-related health condition, known as a comorbidity, such as type 2 diabetes
- have already tried other medical treatments for obesity, which have proven unsuccessful
Requirements can vary depending on a person’s plan type and the state in which they live. However, Medicare will often require the following information to approve coverage:
- Test results within a standard range: The results of adrenal, thyroid, and pituitary blood tests should all be within an expected range.
- Psychological assessment: Individuals must submit the results of a psychological evaluation.
- Proof of prior weight loss programs: People must provide evidence that they participated in at least one weight loss program that was supervised by a medical expert but was unsuccessful.
- Doctor’s order: A doctor or healthcare professional must provide a referral for a qualifying bariatric surgery.
Subsidized Gastric Bypass Surgery
Gastric bypass surgery, also called Roux-en-Y gastric bypass, is a type of bariatric surgery that “bypasses” parts of the gastrointestinal tract to help weight loss.
Medicare offers a subsidized option for gastric bypass surgery if an individual also has one or more of the following conditions:
- heart disease
- gallbladder disease
- osteoarthritis
- high cholesterol
- high blood pressure
- sleep apnea
- stroke
- some types of cancer
- type 2 diabetes
Medicare Part A and B Coverage
Medicare Part A covers inpatient hospital care. This includes services a person may need during an inpatient stay for bariatric surgery, such as nursing care and medications.
Most people do not pay a monthly premium for Part A. However, in 2025, if an individual does not qualify for premium-free Part A, they will pay either $285 or $518 each month, depending on their working history.
Other 2025 costs for inpatient hospital stays include:
- $1,676 deductible for each benefit period
- $419 daily copayment for inpatient stays of between 61 and 90 days
- $838 daily copayment for inpatient stays of between 91 and 150 days while using lifetime reserve days
- 100% of costs for inpatient stays over 150 days
Part B covers outpatient medical services. Covered bariatric services include preoperative and postoperative doctor and specialist visits, as well as any lab tests.
In 2025, most people will pay a Part B monthly premium of $185. This amount may be higher depending on a person’s income.
After a person pays the $257 deductible, they will typically pay a 20% coinsurance toward eligible expenses.
Medicare Advantage
Medicare Advantage plans must cover the same costs toward bariatric surgery as Original Medicare.
Private insurers administer Medicare Advantage plans, each setting its own costs and coverage limits. The premiums, deductibles, copayments, and coinsurance amounts depend on the plan a person chooses.
Some Medicare Advantage plans have preferred networks of doctors, healthcare professionals, and facilities. Care from these providers usually costs less than care from outside the network.
Part D prescription drug plans cover take-home prescription medications.
Weight Loss Surgery Options in Kansas City
The University of Kansas Health System offers discounted, low-cost pricing on weight-loss surgery for those paying out-of-pocket. Their metabolic and bariatric surgeons have performed thousands of procedures. The University of Kansas Health System is proud to provide the lowest price for weight-loss surgery in Kansas City.
The low-cost weight-loss surgery special is only available to candidates paying out-of-pocket and do not have bariatric surgery insurance coverage. Patients must reside in Kansas or the immediate states bordering Kansas. Additional exclusions may apply.