Obesity is a significant health concern, and for some individuals, weight loss surgery, also known as bariatric surgery, becomes a necessary intervention. Understanding insurance coverage for such procedures, particularly through programs like Louisiana Medicaid, is crucial for those who qualify. This article aims to provide clarity on the requirements and considerations surrounding weight loss surgery coverage under Louisiana Medicaid.
Medicaid and Bariatric Surgery: An Overview
Medicaid is a public health insurance carrier that provides coverage to eligible individuals and families. Unlike commercial insurance, Medicaid operates under specific state and federal guidelines. In Louisiana, navigating Medicaid coverage for bariatric surgery involves understanding specific criteria and potential limitations.
Humana is a Coordinated Care plan with a Medicare contract and a contract with the state Medicaid program. Humana and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or expression, transgender status, marital status, military or veteran status, or religion. Humana does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, gender identity or expression, transgender status, marital status, military or veteran status, or religion. They also provide free language interpreter services.
Qualifying for Bariatric Surgery Under Medicaid
To be eligible for weight loss surgery coverage through Louisiana Medicaid, patients typically must meet specific criteria. A key factor is the Body Mass Index (BMI). Generally, individuals with a BMI greater than or equal to 40, or those with a BMI between 35 and 39.9 accompanied by an obesity-related illness, may qualify.
The Role of Senate Bill 106
Senate Bill 106 was a bill requiring that commercial insurance cover bariatric surgery. The new law will make coverage for bariatric surgery available to more than a million Louisiana residents who did not have coverage before.
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Employer-Sponsored Plans and Self-Insurance
It's important to distinguish between different types of insurance plans. While the aforementioned bill impacts commercial insurance, it's important to note that employers who are self-insured are not required to provide bariatric surgery coverage, but they may opt to include it. For many employees the annual benefit enrollment period occurs in the Fall. As your benefit enrollment period approaches you should receive information about your health insurance policy options. Carefully read the coverage, paying attention to the surgery coverage and the exclusions to coverage. If your employer offers more than one policy option, carefully compare the options.
Navigating Coverage Options
Given the complexities of insurance coverage, individuals should proactively gather information and compare options. As your benefit enrollment period approaches you should receive information about your health insurance policy options. Carefully read the coverage, paying attention to the surgery coverage and the exclusions to coverage. If your employer offers more than one policy option, carefully compare the options.
Considerations for Humana Members
Humana is a Medicare Advantage HMO, PPO and PFFS organization and a stand-alone prescription drug plan with a Medicare contract. Humana is also a Coordinated Care plan with a Medicare contract and a contract with the state Medicaid program.
Humana’s pharmacy network includes limited lower-cost, preferred pharmacies in urban areas of AL, CA, CT, DC, DE, GA, IA, IL, IN, KY, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NY, OH, OR, PA, RI, SC, SD, TN, VA, VT, WA, WI, WV, WY; suburban areas of AZ, CA, CT, DC, DE, HI, IA, IL, IN, MA, MD, ME, MI, MN, MO, MT, ND, NH, NE, NJ, NY, OH, OR, PA, PR, RI, SD, VT, WA, WV, WY; and rural areas of AK, IA, MN, MT, ND, NE, SD, VT, WY. There are an extremely limited number of preferred cost share pharmacies in urban areas in the following states: CT, DE, MA, MD, ME, MI, MN, MS, NC, ND, NY, OH, RI, SC, VT, WA; suburban areas of: MT and ND; and rural areas of: ND. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use.
Limitations and Additional Information
It's important to be aware of potential limitations on healthcare and prescription services, which can vary by state. Limitations on virtual visit healthcare and prescription services delivered via remote access technology and communications vary by state. Virtual visit services are not a substitute for emergency care and are not intended to replace your primary care provider or other providers in your network. Out-of-network/non-contracted providers are under no obligation to treat Humana members, except in emergency situations.
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