For individuals struggling with severe obesity, bariatric surgery, also known as weight loss surgery, can be a life-changing option. However, the financial aspect of such a procedure can be a significant barrier. North Carolina Medicaid (NCM) offers coverage for bariatric surgery under specific conditions, outlined in policy A-15. This article aims to provide a comprehensive guide to understanding the requirements and navigating the process of obtaining Medicaid coverage for weight loss surgery in North Carolina.
Understanding North Carolina Medicaid's Bariatric Surgery Coverage (Policy A-15)
North Carolina Medicaid (NCM) offers coverage for bariatric surgery (weight loss surgery) under policy A-15, but eligibility hinges on several factors. The goal is to ensure safe, high-quality surgery for those who need it most.
Key Eligibility Requirements for Medicaid-Covered Bariatric Surgery
Meeting all requirements is crucial for approval. Several criteria determine eligibility for Medicaid-covered bariatric surgery in North Carolina.
Body Mass Index (BMI)
Your BMI must be 35 or higher. (BMI is a calculation of weight relative to height; your doctor can easily determine this.) People with a BMI more than 60 may also be considered on a case-by-case basis. A higher BMI generally indicates a greater need for surgical intervention.
Age
Be between the ages of 18 and 65 years of age.
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MBSAQIP Accreditation
The surgery must be performed at a facility accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). This ensures the facility meets rigorous safety and quality standards. MBSAQIP accreditation signifies a commitment to high-quality care and patient safety.
Medical Necessity
Your physician must certify that bariatric surgery is medically necessary for your health. This involves a comprehensive evaluation considering your overall health, the risks and benefits of surgery, and other treatment options. This certification ensures surgery is deemed the most appropriate and effective course of treatment for your individual needs.
Pre-Surgical Requirements
You may need to complete pre-surgical requirements like nutritional counseling and behavioral therapy. This prepares you for a successful outcome after surgery and helps ensure long-term weight management. These steps enhance your chances of a successful recovery and long-term health improvement. Some insurance programs require patients to participate in a supervised bariatric diet and exercise programs with your primary care provider or our bariatric nurse practitioner. After completing this process, ask your primary care provider or our nurse practitioner to send a letter of support [PDF] to your insurance company.
The Bariatric Surgery Journey at UNC Hospitals
At UNC Hospitals in Chapel Hill or the UNC Hillsborough Campus, you can find the support you need to prepare for successful weight-loss surgery. Expect to spend six to 12 months completing our process and fulfilling your insurance provider’s requirements before surgery. Meet your peers, hear first-hand weight-loss surgery stories, and find out what to expect during your journey. Attend free monthly weight-loss surgery support groups in Chapel Hill or Hillsborough.
Navigating the Approval Process
Working closely with your physician is crucial throughout. Locating an MBSAQIP-accredited facility in North Carolina that accepts Medicaid is a critical step.
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Physician Evaluation
Your doctor will assess your eligibility, completing necessary paperwork and submitting it to NCM on your behalf. Your doctor acts as your advocate throughout this process.
Pre-Authorization
NCM reviews your application. They may request additional information. Pre-authorization signifies initial approval for coverage.
Surgery Scheduling
After pre-authorization, schedule your surgery at the chosen accredited facility. Allowing sufficient time for the entire process is crucial.
Post-Surgery Care
Medicaid may cover some aspects of post-operative care. This involves ongoing monitoring and support to help you maintain your progress.
Appealing a Denied Application
If NCM denies your application, you have the right to appeal. The specific appeal process is outlined in NCM's official policy documents. It is helpful to consult with your doctor or a healthcare advocate to fully understand this procedure.
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Considerations Before Undergoing Bariatric Surgery
Keep in mind that bariatric surgery is a serious undertaking. Anyone considering this type of operation should understand that the surgery will require that you consume fewer calories, and you must commit to permanent lifestyle changes in order to get maximum benefit from the procedure. Your health insurance company may have additional criteria or exceptions for weight loss surgery. You can expect to lose 40 to 65 percent of your excess weight after bariatric surgery.
UNC Hospitals Weight-Loss Surgery Support
Find the support you need to prepare for successful weight-loss surgery at UNC Hospitals in Chapel Hill or the UNC Hillsborough Campus. Expect to spend six to 12 months completing our process and fulfilling your insurance provider’s requirements before surgery. Meet your peers, hear first-hand weight-loss surgery stories, and find out what to expect during your journey. Attend free monthly weight-loss surgery support groups in Chapel Hill or Hillsborough.
Additional Resources
This guide provides general guidance; always consult your physician and NCM directly for the latest information on eligibility and the application process. You must have health insurance through a private provider that covers bariatric surgery for your situation. Also, ask what your insurance provider requires you to do before it will cover your weight-loss surgery. We have options for every step of your journey towards better health. We'll ask you some questions to help build the right solution for you, whether with our surgical team or our non-surgical teams. At your first visit, we'll complete an initial medical assessment with a medical weight loss provider to confirm if medical or surgical treatment is best for you. Our surgical path starts with an intake clinic appointment with a dietitian and bariatric nurse practitioner at our Hillsborough location to discuss the surgical program requirements.
Limitations of Current Information and Future Research Needs
While this guide aims for comprehensive information, the long-term effects of NCM's bariatric surgery coverage policy on both patient access and healthcare costs remain understudied. Further research is needed to provide a more complete understanding of this policy’s impact. More data gathering and analysis from NCM and healthcare providers are vital.