One of the questions we often get from our readers is this – Does Medi-Cal cover Weight Loss Surgery? Does Medi-Cal cover bariatric and gastric sleeve surgery? How do I qualify for weight loss surgery under Medi-Cal? In this post, we are going to provide a detailed answer to these questions.
The US obesity rate is 41.9%. Obesity-related conditions include heart disease, stroke, type 2 diabetes, and certain types of cancer. These are among the leading causes of preventable, premature death, according to the CDC. For some, Weight loss surgery is one of the options for dealing with obesity and related conditions.
Continue reading below to find out if California Medi-Cal covers weight loss programs.
Table of Contents:
- Does Medi-Cal cover Weight Loss Surgery?
- Am I a Candidate for Weight Loss Surgery?
- How much does Weight Loss Surgery Cost?
- How to get Medi-Cal to pay for your Weight Loss Surgery
Does Medi-Cal cover Weight Loss Surgery?
Yes, but it depends on whether you meet the criteria outlined below.
Criteria for Medi-Cal to cover Weight Loss Surgery
In order for Medicaid to cover the cost of your surgery and the associated surgeon visits, you must meet the requirements below.
- Over the age of 13 for a female and 15 for a male.
- Body Mass Index must be over 35 with at least one comorbidity.
- Co-morbidities include sleep apnea, high blood pressure, high cholesterol, and diabetes.
- If you are under 21, you must have a Body Mass Index (BMI) over 40 with at least one comorbidity.
- A letter from your primary care physician stating that weight loss surgery is medically necessary.
- Passes a psychological exam.
- Documentation showing that the patient tried to manage their comorbidities with standard treatment but they were not successful.
- The patient must complete and show documentation that he or she participated in a medically supervised weight loss program for 6 months and it happened within the last 12 months prior to surgery.
- The patient must understand they will be required to change their diet and lifestyle after surgery.
- Nutritional and psychological services must be available before and after surgery (usually from the physician’s office).
Which Weight Loss Surgery Procedures Does Medi-Cal Cover?
Assuming the criteria above are met, California Medicaid covers the following types of Weight loss surgery, which are the most popular:
- Gastric bypass
- Lap gastric bands
- Gastric sleeve surgery
Am I a Candidate for Weight Loss Surgery?
Your physician can best answer this question for you.
However, generally, to qualify for weight loss surgery, you must meet the following criteria established by the National Institutes of Health and the American Society for Metabolic and Bariatric Surgery.
You may qualify for weight loss surgery if you:
- Are more than 100 pounds over your ideal weight or you have a Body Mass Index (BMI) of 40 or greater, or a BMI of 35-39.9, along with two or more medical conditions such as diabetes and/or hypertension which would improve significantly with weight loss.
- Have tried and have been unable to lose weight through diet and exercise.
- Are prepared to make a lifelong commitment to dietary, exercise, and behavioral changes necessary for long-term success.
- Have no mental or behavioral disorders that may interfere with long-term weight loss success.
How much does Weight Loss Surgery Cost?
The cost of bariatric surgery varies based on the type of surgery, patient, and location of the surgery.
However, the average cost of weight loss surgery is between $17,000 and $30,000.
Will Medi-Cal pay for the Entire Cost of Weight Loss Surgery?
Generally, if the surgery is covered under Medi-Cal, there will be full coverage provided.
However, if there is some part of the operation that is not under coverage, then you may have to look for other supplemental insurance or gap insurance to cover the surgery, once you are approved by Medi-Cal.
You can get gap insurance or supplemental insurance after approval for Medi-Cal coverage.
With gap coverage, you can supplement any additional amount with other insurance carriers.
How do I qualify for Medi-cal weight loss surgery?
Medicaid typically requires that there is a medical need for the surgery in order to provide coverage.
As a result, the first step you will want to take in getting approval for your weight loss surgery by your physician.
This is an important step because your physician is able to provide information to Medi-Cal regarding your situation and the medical need for the surgery.
The physician can then refer you to an approved surgeon to assess your situation.
Meeting with an Approved Surgeon
When meeting with an approved surgeon, they will go over the basics of the surgery and discuss your options.
Next, they will run various tests to check out your medical health to make sure you can go through surgery.
After that, they will ask for pre-approval of the surgery from the Medicaid office.
This process can take a good deal of time and you will want to be patient.
Additionally, Medi-Cal and the surgeon may require that you attend classes that discuss the surgery, proper nutrition, exercise, and how to make lifestyle changes after the surgery.
This is often required before they will allow you to have the surgery or start the process.
This is to ensure that you fully understand what is going to happen and what your role in your success after the surgery is going to be.
Summary – Does Medi-Cal cover Weight Loss Surgery?
We hope this post on the question – “Does Medi-Cal cover Weight Loss Surgery?” was helpful.
If you have further questions about Medi-Cal, please let us know in the comments section below.
Be sure to check out our other articles about Medi-Cal and California Medicaid program, including: