Obesity is a growing concern in the United States, affecting a significant portion of the adult and youth populations. It is associated with various health complications, including heart disease, stroke, type 2 diabetes, and certain types of cancer, contributing to substantial healthcare costs. For individuals struggling with obesity, bariatric surgery can be a life-changing option, leading to dramatic weight loss and improved overall health. However, the cost of these procedures can be a significant barrier. This article explores the availability of Medicaid coverage for weight loss surgery, also known as metabolic and bariatric surgery (MBS), and what factors influence coverage decisions.
Understanding Medicaid and Obesity Treatment
Medicaid is a joint federal and state insurance program that provides coverage to specific groups of people, including children, pregnant women, and disabled adults. Traditional Medicaid provides coverage, while expanded Medicaid provides insurance coverage to all adults with incomes up to 138% of the federal poverty level.
The STOP Obesity Alliance and the Obesity Action Coalition reviewed how states cover obesity treatment in their Medicaid programs, considering nutrition counseling (NC), intensive behavioral therapy (IBT), obesity medications (OM), and metabolic and bariatric surgery (MBS).
Medicaid Coverage for Bariatric Surgery
The availability of Medicaid coverage for bariatric surgery varies by state. Some states offer comprehensive coverage, while others have limitations or restrictions.
Georgia Medicaid Coverage
Fortunately, Georgia Medicaid has covered bariatric surgery since 2022. Dr. Abbas and the team at MASJAX in Waycross, Georgia, accept Medicaid patients. However, certain requirements must be met before the procedure will be covered.
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Texas Medicaid Coverage
Medicaid does cover weight loss surgery in Texas, as long as the patient is eligible according to the criteria for coverage. Each state is individual in their Medicaid coverage, and you have to verify with Texas State to see what their coverage is. Weight loss surgeries are not extensively mentioned in the rules and guidelines for Medicaid coverage but are handled separately for different cases. It is important for you to work with your physician to discuss the approval process for Medicaid coverage. You can get in touch with Dr. Mustafa H.
Qualification Criteria for Bariatric Surgery Coverage
The essential qualification criteria revolve around the concept of medical necessity. If the insurance company believes bariatric surgery is necessary for the patient’s continued or renewed health, it is typically covered. While specific criteria vary by state and insurance plan, some general requirements include:
- Body Mass Index (BMI): A BMI of 40 or higher, or a BMI of 35 or higher with one or more obesity-related comorbidities.
- Comorbidities: Significant health problems related to obesity, such as type 2 diabetes, hypertension, sleep apnea, or cardiovascular disease.
- Prior Weight Loss Attempts: Documented evidence of unsuccessful attempts to lose weight through diet, exercise, and other non-surgical methods.
- Psychological Evaluation: A psychological evaluation to assess the patient's mental and emotional readiness for surgery and their ability to adhere to post-operative guidelines.
- Commitment to Lifestyle Changes: A willingness to adopt and maintain long-term lifestyle changes, including dietary modifications, regular exercise, and ongoing follow-up care.
- 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.
- There is a demonstration of participant responsibility. 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.
- 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.
- Education regarding risks and benefits of bariatric surgery and procedural options.
Reasons for Non-Qualification
Certain patients will not qualify for coverage of their bariatric procedure. Of course, this includes anyone who still needs to meet the physical prerequisites for coverage. Patients with certain conditions and diseases may not qualify, including:
- Active suicidality
- Active or recent (within one year) substance abuse
- Active psychosis
- Blood clotting disorders
- Pregnant patients or those planning to be pregnant
- Those unwilling or unable to follow post-op care instructions
These details can be discussed during consultation. Of course, our number one concern as bariatric surgeons is safety and effectiveness.
Covered Bariatric Procedures
Medicaid typically covers the most common and well-established bariatric procedures, including:
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- Gastric Sleeve: The gastric sleeve, also known as sleeve gastrectomy, is a combination restrictive/hormonal procedure offering excellent potential results. Yes, the gastric sleeve may be covered by Georgia Medicaid in qualifying patients. The gastric sleeve is our Georgia location’s most commonly performed bariatric surgery.
- Gastric Bypass: Some patients will be better suited to a gastric bypass versus a restrictive procedure like a gastric sleeve. This is especially true for patients with uncontrolled or poorly controlled reflux (GERD) or type-2 diabetes. In most cases, Medicaid covers gastric bypass, gastric sleeve surgery, and Lap-Band Surgery. These are not only easily converted by Medicaid, but also among the most standard surgeries recommended.
- Lap-Band Surgery
Less common procedures, such as the duodenal switch and SADI, may not be covered by all Medicaid plans. You may have been made aware of procedures, such as the duodenal switch and SADI, during your research. These are exceptionally effective procedures, especially for patients with very high BMIs. Georgia Medicaid does not currently cover them.
Revision Procedures
As with most insurance coverages, revision procedures are considered case-by-case. Why would one need a revision procedure? Ultimately, not every bariatric patient will be successful. While a procedure failure is rare, patients may commonly stretch their gastric pouch over time and begin to regain weight. We can usually arrest this weight gain with proper aftercare before it becomes problematic, but for some, a follow-up surgical procedure is necessary.
The criteria that must be met for a repeat bariatric and metabolic surgery to be approved includes a requirement that the patient (and/or provider) provide proof of compliance with all previously prescribed postoperative nutrition and exercise programs.
The Impact of Bariatric Surgery on Medicaid Coverage
Bariatric surgery leads to dramatic weight loss and improved overall health, which may affect insurance status for certain patients. A study examining patients who underwent bariatric surgery found that a significant percentage lost Medicaid coverage one year after surgery.
One year after bariatric surgery, 41.6% of patients covered by Medicaid for their surgery no longer had this coverage. In general, these patients had lower rates of medical comorbidities, including diabetes mellitus (44 vs 32%, p=0.02), and lower BMI (56.1 ± 11.0 vs 53.7 ± 11.1 kg/m2, p=0.04) preoperatively. Of the patients no longer covered by Medicaid, 49.0% no longer had insurance coverage and were listed as self-pay at one year. This accounted for 20.4% of the entire population resulting in no coverage falling into the self-pay category. Patients with self-pay status at 1 year were significantly younger (34 vs 38 years, p<0.0001) and generally had lower preoperative BMI (52 vs 56 kg/m2, p= 0.02).
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This loss of coverage can be attributed to improved health outcomes and a return to work, making individuals no longer eligible for Medicaid. However, it also raises concerns about access to long-term care and follow-up, which are crucial for maintaining the benefits of bariatric surgery.
Access to Comprehensive Obesity Care in Medicaid Programs
The review of Medicaid coverage included the elements of comprehensive obesity care: nutrition counseling, intensive behavioral therapy, obesity medications, and metabolic and bariatric surgery.
Nutrition Counseling
Few states were explicit about NC for obesity treatment unless it was tied to metabolic and bariatric surgery requirements. Few states were explicit about this coverage; therefore, fee schedules were used to interpret coverage where necessary. The state covers nutrition counseling.
Intensive Behavioral Therapy
Few states were explicit about this coverage. The state covers intensive behavioral therapy.
Obesity Medications
The obesity medications (OM) considered were the new generation medications, including Saxenda and Wegovy, and the older generation medications, including Contrave, Qysmia, Phentermine, Benzphetamine, Diethylpropion, and Phendimetrazine. Xenical, Orlistat and Alli are older generation medications that are now available over the counter. The state will cover obesity medications for the specific purpose of treating obesity (not to treat Type 2 diabetes with obesity as a secondary condition). There are no limitations or restrictions to coverage, and the state offers both new generation (Saxenda and Wegovy) and older generation (Contrave, Qysmia, Phentermine, etc.) medications. The drugs covered for obesity were reviewed from the state fee for service (FFS) and the managed care organization (MCO) Prescription Drug List (PDL) of the MCO with the greatest number of enrollees. There are restrictions on coverage based on age. The patient must achieve a specific amount of weight loss for the medication to be renewed.
Navigating the Medicaid Approval Process
Navigating the Medicaid approval process for bariatric surgery can be complex. Here are some steps to consider:
- Consult with Your Physician: Discuss your weight loss goals and health concerns with your physician. They can help determine if bariatric surgery is a suitable option for you and recommend approved surgeons. It is important to have a physician who can share vital information for the medical necessity of weight loss surgery for the patient. Further, a physician can also recommend the patient to approved surgeons.
- Contact Your Local Medicaid Office: In most cases, Medicaid covers gastric bypass, gastric sleeve surgery, and Lap-Band Surgery. These are not only easily converted by Medicaid, but also among the most standard surgeries recommended. It can be difficult to determine what part of your surgery will be covered by Medicaid in your area. You can check the same with the local Medicaid office to see where this information can be available for you.
- Attend Informational Classes: Prior to approval, you may need to attend classes to gain knowledge about the surgery, lifestyle changes, exercise, nutritional needs, and so on. These are important for post-operative care.
- Undergo Necessary Tests and Evaluations: After taking the decision, you have to go through certain tests and then consult the Medicaid office for the pre-approval of your surgery. This includes medical prep, X-rays, and blood tests. With all the necessary provisions, chances are you will get approval from Medicaid. These provisions can then include other additional classes or more testing.
- Work with Approved Surgeons: At Nova Bariatrics, we have experienced approved bariatric surgeons Dr. Gulamhusein and Dr. Approved surgeons help you understand the basics of the surgery and the various options at your disposal.
- Prepare for Post-Operative Care: After Medicaid approval, your surgeon has to determine if you are fit to undergo the procedure.