Weight Loss Surgery and Medicare

What Is Weight Loss Surgery?

Weight loss surgery is growing in popularity. It has helped many people lose weight and can produce dramatic results. Medicare has been covering weight loss surgery for beneficiaries since 2005.

The surgery works by either reducing the amount of food that fits in the stomach or by restricting how much the stomach can digest. Also called bariatric surgery, bypass surgery, gastric banding or obesity surgery, it can be a good option for people who have not been able to lose weight with conventional methods, including seniors.

About 95% of people who have had the surgery claim it has improved their quality of life. Research backs that up; comparisons show that obese people who have had the surgery live longer than those who have not.

However, weight loss surgery may not be for everyone. While considered safe, this surgery has some risks. Also, weight loss is not guaranteed. The patient must be willing to follow their doctor’s diet and exercise recommendations.

What Are the Benefits?

In addition to losing weight and increasing quality of life, most people have improved health. For example, medical conditions related to obesity commonly improve or will sometimes even disappear. Those conditions include:

• Diabetes
• Severe arthritis
• Obstructive sleep apnea
• High blood pressure

What Are the Risks?

As many as 10% of patients experience complications with weight loss surgery, with approximately 1 in 400 dying as a result. The risks include:

• Nausea, vomiting and diarrhea
• Infections
• Stomach hernias
• Bood clot(s) in the lungs
• Internal bleeding
• Ulcers
• Heart attack

Even after successful weight loss surgery, other related health problems may occur, including:

• Gallstones
• Malnutrition from poor food absorption
• Excess skin requiring surgical removal

Are the Health Risks Higher for Seniors?

As with all surgeries, there are risks no matter what the patient’s age. However, while the weight loss surgery risks do increase with age, many experts feel that seniors can safely have the operation provided they are in good health. A complete health assessment prior to surgery is suggested.

In one Mayo Clinic study, researchers compared older and younger patients who had the operation. They found that younger patients lost more weight and had slightly better improvement in their health while older patients did better in other areas. For example, older patients had a greater reduction in the number of post-surgery medications and were more likely to comply with diet and exercise recommendations.

Who is Eligible for Medicare Coverage of their Weight Loss Surgery?

To qualify for coverage you must meet the following criteria:

• Have a BMI of 35 or greater
• Have at least one weight-related problem (diabetes, heart disease or sleep apnea)
• Documented evidence (in your medical records) of repeated failure to lose weight in medically supervised weight loss programs (diet, exercise programs/counseling or drug therapy)
• Have a psychological evaluation
• All other medical treatments have been ruled out
• The surgery must be performed at a Medicare-approved “Center of Excellence”
• The specific procedure used is approved by Medicare

What Will Be My Cost for this Surgery?

Your out-of pocket costs will depend on which type of plan you receive your Medicare coverage from. If you receive your coverage through:

• Original Medicare Plan: Medicare covers 80% of the approved amount. You are responsible for the remaining amount.
• MediGap/Medicare Supplemental Plan: Call and ask what is covered by the plan. Many times with MediGap plans, you will pay little or nothing.
• Medicare Advantage Plan:  Call your plan and ask about costs. The plan must cover at least what Original Medicare does, but it may cover more.

Where Can I Find a Doctor Who Does the Surgery?

Ask your doctor for recommendations for a local Medicare-approved center. The Centers for Medicare & Medicaid Services (CMS) website has a complete list of approved centers for bariatric surgery at www.cms.gov.

Other important things to know:

• Medicare will not pay for the surgery unless it is completed at a Medicare-approved "Center of Excellence" for bariatric surgery.
• You must have paid your annual deductible for services and supplies before Medicare will begin to pay its share.
• Your costs will be different if you receive your care through one of the Medicare Advantage plans. Call the plan and ask about your share of cost.

You may pay little or nothing if you are covered by a MediGap/Medicare Supplemental plan. Call the plan and ask about your share of cost.