Medicaid’s requirements for weight loss surgery coverage are a little different as compared to other insurance plans. Typically, this is because Medicaid is unique in who they cover and how they cover their patients.
You need to meet a number of specific requirements in order to qualify for weight loss surgery through Medicaid, and you also need to be free from any medical issues that would prevent you from having surgery. If you pass these two tests, then Medicaid will generally pay for your weight loss surgery.
Criteria for Weight Loss Surgery Cost Coverage Through Medicaid
In order for Medicaid to completely cover the cost of your surgery as well as the associated visits with your surgeon, you are going to need to meet all of the following criteria.
- You will need to be over the age of 13 if you’re a female or over the age of 15 if you’re a male.
- Your Body Mass Index (BMI) must exceed 35 and you must have at least one comorbidity, such as high blood pressure, sleep apnea, high cholesterol, or diabetes.
- If you are below the age of 21, you need to have a Body Mass Index (BMI) exceeding 40 with at least one of the aforementioned comorbidities.
- You must have a printed letter from your primary care physician recommending the medical necessity of weight loss surgery.
- You need to pass a mental health exam showing that you are capable of adopting the necessary lifestyle changes for weight loss.
- You must be able to provide documentation showing that you have tried to manage your weight and comorbidities using standard treatment, but that those attempts were unsuccessful.
- You must complete a medically supervised program for weight loss spanning 6 months, and you need to show documentation that this weight loss program was attempted within the past 12 months before surgery.
Some people will not qualify for weight loss surgery through Medicaid. If you have any of the following conditions or issues, you will not qualify.
- Long-term use of steroids
- Malignant cancer
- Chronic pancreatitis, inflammatory bowel disease, or pregnancy
- Non-compliance with medical treatments
- Psychological treatment that could interfere with your new diet and lifestyle
What Weight Loss Procedures Will Medicaid Cover?
Assuming that you meet all of the criteria mentioned above, Medicaid will pay the coverage for the following weight loss surgery procedures:
Other Considerations for Medicaid
One of the requirements for Medicaid to pay for your surgery coverage is that you need to have your weight loss surgery done through a Center for Excellence. Bariatric Center for Excellence accreditation is designed to indicate which bariatric surgery centers have achieved a level of excellence when it comes to administering bariatric surgery. Medicaid requires that you visit one of these specific centers to guarantee that you get the best possible treatment.
Related: How to Appeal Insurance Denial for Weight Loss Surgery
If you have questions about your Medicaid coverage and whether or not your coverage will pay for weight loss surgery, the best thing to do is to contact the people at Medicaid directly to discuss your coverage. There are many types of surgery that you can undergo weight loss, but Medicaid only covers the most common ones.
If you’re looking to have a different type of weight loss surgery aside from gastric bypass, lap gastric banding, or gastric sleeve surgery, then you will need to look for a different type of insurance coverage or you will need to pay out-of-pocket for the procedure.
*Medicaid will not pay for weight loss surgery in Mexico
Resources:
My daughter is 18 she is 330 lbs diabetic her doctor has been trying to find a doctor to take medicaid we cant find one we live in sheffield alabama
I’m a 50 years old woman with Medicaid in Oklahoma. I’m overweight and I need knee surgery on one leg and hip surgery on the other. My nerves in the right is unbelievably horrible. I have tired to lose weight and I can not just sit around and lose weight. I have always been overweight, but I could walk. I have to get my knee surgery like yesterday. If I can’t walk I can’t lose weight. My knee is bone on bone. Can I get Medicaid to help me?
I’m on medicaid and need help with what I need to do. And where to go first. I’m 52 years old and weigh 264.4 lbs. I’m ready to start the process today. I do take blood pressure medication. When you have time please let me no what I need to do and where to go
Thank you so much and stay safe.
Hello, my name is Juliette and I have Medicaid with Molina and I would like to know if the weight lost surgery is covered.
Have you had any luck? I’m needing to know the same
It is covered I’m currently goin thru the 6month diet process u have to do Medicaid makes it mandatory.
The criteria is not very clear BC my BMI is 38, I have high blood pressure, high cholesterol, depression, thyroid issues (on medication for all) and will be getting a sleep study done, and I have United Medicaid BUT when my PC sent my papers to Oshner they declined me bc I never had a stroke and the sleep study results have to be severe for United to cover. I just think the information is misleading and should be more in detail about the criteria.
You will get denied until you complete All The Criteria not just have it scheduled.
I have medicaid I’m at risk for diabetes I have sleep apnea my BMI is 42.2 . I am 25 years of age I don’t know if it is the best idea to get this surgery but I’ve been considering it
How long after completing the weight-loss program do you receive surgery with medicaid?
Which states do accept Medicade? I’m in Florida
Willie Harper in Jonesboro Arkansas
I had the full gastric in 2009. But the last six months I have gained 49 pounds. I’m out of control. What has happened. Is there surgery for this.
I had the full gastric in 2009. But the last six months I have gained 49 pounds. I’m out of control. What has happened. Is there surgery for this. Do I need a redo
Are you actually willing to put your body through that twice? My guess would be that you need to do better with counting calories and limiting your intake. YOU CAN DO IT!!! I know it is hard, because I struggle too. I haven’t had surgery but I know the feeling of losing weight only to gain it right back. I wish us both much success with our weight loss goals.
Hello , my name is Laura. I had mine done in 2011 and have gained a big amount back. I was very upset , but was informed by my bariatric doctor that it in fact can happen after several years. It’s not counting calories , it’s your pouch getting loose and allowing for more intake. Many people have to get revisions. I will be one of those after I was down with an injury for almost three years. Starting all over.
I am 33 with high cholesterol have been on a nutritionist diet for seven months and have not lost any weight even with exercising daily. Only 5’6 230 pounds. Really need to the nessary next step to get procedure approved
Hello, my name is Margaret am 56 my BMI 43, I’m a diabetic, medical high blood high pressure, I have Humana, and MI medicaid would I qualify.
Please i really want to meet with Dr now…
Can you have it done twice? I had it done about 7 years ago
How does it work Lithonia
I’m interested in the gastric sleeve. I have been over weight my whole life however from January to June of 2022 I have gained an excess of 50 pounds I truly believe this is my best option I have tried cutting everything out of my diet exercising daily but nothing has worked
Hello Hillary,
Your first step would be to fill out a health questionnaire with our collaborative partner, Mexico Bariatric Center. It’s free and confidential. These doctors can examine your medical history to see if you are an ideal candidate.
https://mexicobariatriccenter.com/health-questionnaire/
MY WEIGHT IS AFFECTING MY LIFE I DON’T WANT TO GO ANYWHERE NOT EVEN OUTSIDE TO WALK MY DOG ,I GO OUT HOPING NO ONE WILL BE OUTSIDE TO SEE ME BUT I HAVE TO FOR MY DOG ,THANK GOD FOR GIZZMO BECOME I WOULD HIDE IN MY HOME ONLY TO GAIN MORE WEIGHT, I DON’T KNOW WHAT TO DO. I’M ON MEDICAID I NEED HELP!!!
Hello Ginger,
My best advice would be to speak with your personal doctor about possible treatment or surgery for weight loss. We do work exclusively with a US-based company, Mexico Bariatric Center, which offers affordable weight loss procedures in Tijuana, Mexico. If you would like to know if you qualify, feel free to fill out a health questionnaire. It’s free and confidential.
https://mexicobariatriccenter.com/health-questionnaire/
I have several of the co morbidites and am 55 250 pounds. However I have Chronic pancreatitis. Why is that something Medicaid rules out for gastric surgery?
Unfortunately, different insurance providers have other criteria. There are other solutions for weight loss surgery without insurance coverage. Be sure you put yourself first and do whats best for you.
I started with a BMI of 40 which I qualified for Medicaid to cover me. If my bmi changes to like 38 a month before seeing my surgeon due to just my weight always fluctuating, Will Medicaid still cover because now my bmi isn’t at 40 anymore??
Hi Sandra, you will have to contact Medicaid or your surgeon directly.
I am 53 have bmi of 32.5. I have neuropathy in both legs, lower back issues and use a walker that limits my ability to excercize. I also have compensated endstage cirrhosis, bypolar depression with mania and high blood pressure which I take medicine for but still flucuates. My weight went up to 220 lbs four years ago and I lost 30 lbs within 2 years following my Drs diet pamphlet. I can’t seem to loose anymore and have even gained. Other than to stop eating all together I don’t know what more I can do. I have UnitedHealth care dual complete( Ohio) are there other health pro blems and BMI they will consider to cover bariatric sleeve surgery?
Hi Stacey, It is recommended to speak with United Health Care directly to find out what requirements must be met in order for them to cover your bariatric surgery.