Which US states do/don't cover bariatric surgery? Answers here.

[Seastars 175]

For those considering surgery who, like me, were investigating insurance coverage, the following info might be useful. Basically: <b>in about half of US states it is nearly impossible to get insurance coverage for bariatric surgery, regardless of your BMI or co-morbidities,</b> regardless of the specific surgical procedure and regardless of where you get the surgery.

Prior to the Affordable Care Act (Obamacare), private insurers largely had free rein to exclude treatments (such as for obesity and other pre-existing conditions) and increase premiums for the obese. Only 4 states required insurers to cover bariatric surgery. So insurance coverage for weight-loss surgeries was inconsistent across the country (but tended towards exclusion).

2012's ACA changed that, with a federal mandate for insurers to cover bariatric surgery and nutritional counseling/weight loss plans. But there's a huge exception: states can individually opt out of some of this federal mandate. (That's crazy and defeats the universal-coverage intent of the statute in my opinion.) So, 23 states now require Medicaid (low-income state insurance), exchange (non-employer-provided) and private (group plan through your employer) insurers to cover bariatric or gastric bypass surgery (although the specific insurer can limit it, say to a BMI of 40 or above, or 35 with 1 or 2 co-morbidities). Yay! <b>These states where insurers are required to cover bariatric surgery are: Arizona, California, Delaware, Hawaii, Illinois, Iowa, Maine, Maryland, Massachusetts, Michigan, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Oklahoma, Rhode Island, South Dakota, Vermont, West Virginia, Wyoming.</b>

In addition,three states provide that "coverage must be offered..." in at least some policies, but it is not required in all policies. These are: <b>Georgia, Indiana, Virginia.</b>

But 24 states -including mine - still allow insurers to entirely exclude coverage for bariatric surgery. And in those states where it's allowed to be excluded, almost all insurers DO exclude it, because bariatric surgery is expensive and usually increases insurance premium cost. So the exchange insurers, to be competitive in the insurance market, exclude it. Most employer-provided plans, ditto. A few private, employer-offered, generous group insurance plans may cover it but this is rare, because of the higher premium cost. <b>These states in which insurers are allowed to, and usually do, exclude bariatric surgery are: Alabama, Alaska, Arkansas, Colorado, Connecticut, Florida, Idaho, Kansas, Kentucky, Louisiana, Minnesota, Mississippi, Missouri, Montana, Nebraska, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Washington, Wisconsin.</b>

SO, if you are in one of the 27 states where insurers aren't required to cover bariatric surgery, very likely any insurance you can get (from your employer or the exchange/open market) will not cover it, regardless of BMI or co-morbidities. If you live in one if those states, as I do, you will almost certainly have to self-pay for the surgery.

Here is a good, recent (March 2016) article detailing what I've just summarized: http://www.ncsl.org/research/health/aca-and-health-mandates-for-obesity.aspx

I know this is long but it may help someone reading to understand why his or her insurance policy excludes bariatric surgery entirely, when so many posters on this website seem to have insurance coverage. Don't be dismayed. Confirm your coverage (call the customer service number on the back of your insurance card) and then assess whether the cost of funding the surgery yourself is worth the health benefits. (For me, it is.) Good luck!

Thanks to Silverthreads for help with this post.

[della street 213]

I live in AZ and for many years, hubby's employer-based policy (that also covered me) specifically excluded WLS surgery "even in cases of imminent death" (exact quote I will never forget from insurance company representative, ugh...)

I am self-employed, and in Oct of 2014, I purchased a BCBS plan on the ACA Marketplace ("Obamacare") for just myself to cover me in 2015. We make too much $$ for a subsidy, but between the savings in not being on hubby's plan and what this plan cost, the difference was about $300/month - not insubstantial, but do-able, considering the policy covered WLS.

I carried that policy all through 2015, going back on hubby's policy in Jan. 2016.

I had gastric bypass surgery in January 2015 and have since lost approx 130 lbs (plus 50 lbs on doctor-supervised too-strict-to-follow-forever diet prior to that) for a total loss of approx 180 lbs over the last three years - 130 of which is directly attributable to WLS surgery. Since then, I no longer have sleep apnea, not pre-diabetic, all blood-work tests are good, and my quality of life is immeasurably improved!

I feel incredibly fortunate that AZ, which is a state that is very backwards (IMHO) on many legislative-type issues, actually covers this - I was pretty shocked as a matter of fact. So while there are good/bad things about everything, to me, "Obamacare" and the ability to purchase my own insurance plan without regard to prior conditions (ie, obesity), literally saved my life.

PS - these types of state-sponsored restrictions cover several other medical area such as infertility treatments and much more, as well - there are state-by-state coverage-mandates...