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Getting to Know Your Insurance
Getting insurance coverage for bariatric surgery can be a challenging process. Many patients face roadblocks in this process, like insurance denials. Being prepared with the right information can help give you the upper hand. Insurance plans differ greatly, and working to understand your plan is an important step as you work to get coverage for surgery.
To start, review your insurance policy or employer-sponsored medical benefits plan to learn whether your policy is fully-insured or self-insured, and to determine if there are any policy exclusions. This will help you learn whether or not you will be covered for bariatric surgery.
You should be able to answer these questions when determining what coverage and the type of coverage that you have:
- What are your health insurance benefits?
- What is the definition of “severe obesity” (morbid obesity) according to your plan?
- If any, what coverage of severe/morbid obesity is listed?
- What limits and/or requirements are stated in order to receive severe/morbid obesity treatment? For example:
- Is there a certain amount of required time you must document attempted weight loss?
- Does the documented time have to be consecutive?
- Is your physician required to document your weight loss attempts?
- Do you need to weigh a certain amount before treatment is performed and/or initiated?
- Is there a certain amount of weight that must be lost prior to surgery?
- Is there an age requirement to receive care?
- Must you use a specific Center of Excellence or medical provider to receive coverage?
- Are there weight limitations preventing coverage?
- Is there a maximum dollar limit on your benefits? What treatment options are excluded or specifically included?
- What is the co-payment for medical services?
- What testing will be required and covered, such as nutritionist, psychologist, labs, sleep apnea study, ultrasounds, etc.?
Learn more about insurance pre-approval and working with your doctors and insurance providers. Read this sample letter to help when contacting your employer about including bariatric surgery coverage in your plan if it isn’t currently covered.
This content is adapted from The OAC (Obesity Action Coalition) Insurance Guide.