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The Truth About Medicaid And Weight Loss Surgery

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Lady S.

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There are many myths about Medicaid and Medicare when it comes to weight loss surgery. For more than 10 years I put off surgery because I had Medicaid and then Kaiser. When asking the insurance company if weight loss surgery is covered, they will always tell you no. The best place to start is reviewing your 'what's covered' excerpt in your manual. Many health insurance companies will cover your surgery as long as it is medically necessary. A medical necessity is these three things:

1) BMI over 40

2) Two Morbidity (i.e. diabetes, high blood pressure, sleep apnea, heart condition, etc.)

3) Pre-op weight loss.

 

These are the guidelines for most insurance companies, but I really wanted to discuss Medicaid/Medicare. Medicaid in most states will cover your surgery as long as you meet their guidelines for medical necessity. The first place to start is with your PCP. If you make your PCP aware that you are considering weight loss surgery, they will be able to refer to you to a surgeon that accepts your insurance. The surgeons are familiar with the procedure and will get the surgery approved as long as you qualify.

 

Depending on your state, Medicaid will allow certain procedures. In Ohio the Gastric Sleeve is not accepted for the weight loss surgery, but Lapband and Bypass are. This is the step that you stay in constant contact with your surgeon and they will have a specialist that handles all insurance questions that knows these companies in and out.

 

The surgery will not happen quickly, the normal wait time for Medicaid/Medicare is nine (9) months. You report to your surgeons office once per month for weigh ins and follow-up with dietitian and the surgeon. There are also several tests are required. I would suggest doing them as soon as possible, this way if there are any additional tests that need to be conducted, you have time to get them done.

 

Because most states have opted to provide their Medicaid/Medicare in *** form, it actually works a lot better than if it were strictly run by the State. My insurance is Molina of Ohio (Ohio Medicaid), I was approved for surgery after the 1st request. My surgery was paid for 100% without complication. The nine month waiting period gives you time to make sure that this is the right choice for you , and also begin changing you lifestyle. So if someone tells you that weight loss surgery is out of the question because you receive Medicaid/Medicare, this is not at all true. Check your manual and with your PCP, if you have any questions I may be able to assist. I hope that this blog helps people understand that there is hope for those that struggle with their weight and receive public health benefits.

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I have never had medicaide but I have medicare and went through most of what you are talking about here. I believe the law has changed to 35 bmi but there I had no problem. I had to go through 6 months diet, a nutritionist, and a psychologist. When you do to the seminar they will tell you what your insurance will cover. I know here in VA some of the Surgeons will not even see you until you have all the other parts done.

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I also have Medicare and had no problem. In fact, I went to my first seminar on December 15th and I was banded less than a month later on January 6th. No waiting period or anything.

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I also got banded with Medicare. Only needed 1 comorbitity (HTN) and didn't have a waiting period at all. In fact, I had my seminar on Sep 15th, saw the nutritionist and psych on Sep 20th and was banded on Oct 1st. I wish I had done more research before tho. Not that I'm not happy with my 104 lb loss - I am. I wish I knew then that until my band was adjusted properly (about 5 mths) I wouldn't lose any weight. I thought it would magically come off.

Just wanted to let you know that I was Medicare also and I had no waiting period. This was in OR - but I don't think it matters for Medicare

Marci

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I have medicaid and was approved in 3 weeks. I have two comorbidies of type two diabetes and high cholestorol. hope this helps.

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I also have medicaid in Ohio (Caresource) and am being covered - doing my 9 months now. But I also wanted to add that if your BMI is over 50, you only need one comorbidity according to my doctor and my surgeon's paperwork.

Thanks for posting this, I know I was really confused about this stuff when I first started thinking about WLS.

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Mis73 I thought u said in another post that Medicaid wasn't covering it anymore? Now you HAVE Medicare? Hmmmm....anyway, I have Medicaid and live in Connecticut and I had to do the 6 month weigh ins ....all in all everything took me almost a year...I had to do many many tests as well. Dietitian wasn't covered though I had to pay for that. It took less than a week for me to get approved...and I'm now scheduled for February 8th!! wink.gifBut I am glad that it took as long as it did, because it gave me more time to think about this and research and now I'm more ready than I ever was...and have been exercising and lost weight too! !

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Thank you all for your responses and posts. All these comments will help others that are in our situation. I know that requirements vary from state to state, so it is so great that you have posted your experiences. When I started my Journey, I was confused and unsure where to start and was told that medicaid does not cover WLS. Congrats to all that are beginning their journey, and same to those that have had the WLS.

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