Does Medicaid Cover Bariatric Surgery?

Medicaid is a federally funded healthcare plan that provides healthcare coverage to millions of low-income individuals and families who otherwise would not be able to afford coverage., Medicaid is a crucial program designed to fill gaps in essential healthcare. While Medicaid is federally funded, it is a joint federal and state program, which means Medicaid eligibility and coverage can and does vary from state to state.

Medicaid Origins

Medicaid was established in 1965 as part of the Social Security Act. It is currently administered by the Centers for Medicaid and Children’s Health Insurance Program Services, which monitors each state’s program.

Medicaid is available in all states, the District of Columbia, and U.S. territories. The Affordable Care Act passed in 2010, substantially expanded the Medicaid program, making anyone earning up to 138% of the Federal poverty level potentially eligible for coverage. To date, 41 states have adopted the Medicaid expansion and 10 states have not.

Medicaid Eligibility Criteria

Medicaid eligibility is two-fold. Federal guidelines determine a minimum standard for eligibility. However, each state has the flexibility to expand coverage beyond those minimums.

General eligibility is based on the following factors:

• Income
• Family size
• Disability status
• Age
• Citizenship or immigration status
• State residency

Income eligibility is usually based on Modified Adjusted Gross Income (MAGI). Some individuals are exempt from MAGI-based income criteria, which may include those with blindness, disability, or age 65 or older.

Other exemptions for financial eligibility criteria may include individuals enrolled in another program, such as SSI or the breast and cervical cancer treatment and prevention program, children for whom an adoption assistance agreement is in effect, or young adults eligible as former foster care recipients.

Medicaid Coverage and Benefits

Because states have the option to offer benefits in addition to the mandatory benefits set by the federal government, which include hospitalization, physician services, and laboratory services, to name a few, the disparities in coverage can be substantial and confusing when a Medicaid recipient moves from one state to the next.

Below are some of the additional services states may elect to provide Medicaid beneficiaries:

• Dental
• Vision
• Mental health treatment
• Substance abuse counseling
• Bariatric procedures
• Home-based care services

In addition, some states can apply for waivers from certain federal Medicaid regulations to account for different population needs and circumstances. These waivers give states the flexibility to try alternative approaches to delivering healthcare services. This could include changes to eligibility, coverage, and even cost-sharing.

It’s easy to see how coverage and healthcare gaps can vary for Medicaid beneficiaries depending on their state of residency.

Weight Loss Through Bariatric Surgery with Medicaid

Obesity often leads to many other health issues. More and more people are turning to bariatric surgery when traditional weight loss measures are unsuccessful. Medicaid typically covers bariatric surgery, but regulations can vary from state to state.

In the instances where it is covered, eligibility requirements must be met and may include the following:

• 21 years of age or older
• Body Mass Index (BMI) of 35 or greater with at least one comorbidity, such as high cholesterol, diabetes, sleep apnea, or high blood pressure.
• Under age 21 and a BMI of 40 or greater with comorbidities
• Letter of recommendation from your primary care physician
• Documentation of unsuccessful attempts at standard weight loss treatments within 12 months before surgery and lasting for at least six months
• Surgery performed at a Medicaid-approved Bariatric Center of Excellence

The types of bariatric procedures potentially covered by Medicaid are limited to gastric bypass, gastric bands, and gastric sleeve surgery. However, in certain states, reimbursement can be very low, so some bariatric practices will not accept Medicaid.

Managed Care vs. Fee-for-Service

With Medicaid, states may offer benefits one of two ways: on a fee-for-service (FFS) basis or through managed care plans. With FFS, states pay providers directly for covered services received. Under managed care, the state pays a fee to a managed care plan for every enrolled individual. The plan then pays for the Medicaid services rendered. Most Medicaid plans are administered under managed care.

Next Steps

With many regulations and variability in Medicaid coverage between states, the process of surgery can be confusing. Please speak to your bariatric practice or Medicaid administrator to learn more about your options and the requirements needed for coverage.