• Gastric bypass surgery is one of the most popular and successful types of bariatric surgery.
  • Gastric bypass is covered by Medicare under three conditions: a BMI of 35 or above, a comorbid condition, and previous unsuccessful attempts at medical weight loss.
  • Although gastric bypass surgery averages around $15,000, most Medicare beneficiaries only pay standard plan costs.

Gastric bypass, medically known as Roux-en-Y gastric bypass, is a type of bariatric surgery that involves “bypassing” parts of the gastrointestinal tract to aid in weight loss. Hundreds of thousands of people undergo bariatric surgeries like gastric bypass each year, some of them are also Medicare beneficiaries.

If you’re a Medicare beneficiary who is planning to undergo a gastric bypass in 2020, you may be covered by your Medicare plan if you meet certain criteria.

In this article, we’ll discuss the requirements for Medicare-covered gastric bypass, what parts of Medicare cover the procedure, and what to know about choosing the best plan for your gastric bypass surgery.

According to one study from 2018, gastric bypass surgery is one of the most popular bariatric surgery options for Medicare beneficiaries. The Centers for Medicare & Medicaid Services (CMS) states that Medicare covers gastric bypass surgery for beneficiaries who meet the following conditions:

  • a body mass index (BMI) of 35 or higher
  • at least one comorbid condition resulting from obesity
  • a previous unsuccessful attempt at losing weight through medical means

Medicare will cover both open and laparoscopic gastric bypass surgery if the conditions listed above are met. However, this gastric bypass surgery must be performed at a facility that is certified by either the American College of Surgeons or the American Society for Bariatric Surgery.

As long as the requirements are met for Medicare coverage, any services related to the surgery, including the diagnosis, procedure, and recovery, will be covered by Medicare. This includes services such as:

  • lab testing and exams before the procedure
  • surgical services during the procedure
  • hospital room and board after the procedure
  • additional testing or bloodwork after the procedure
  • any medication or durable medical equipment during recovery
  • checkups with the doctor and other specialists during recovery

Gastric bypass surgery costs can vary greatly, depending on the hospital you visit, the surgeon you choose, and more. According to a 2017 study, the average cost of bariatric surgery in the United States — including gastric bypass procedures — was almost $15,000.

However, if you are covered by Medicare, your Medicare plan will cover most of these procedure costs. Your Medicare plan will also cover any other services you need related to the procedure, such as diagnosis and recovery services. The only costs from your gastric bypass procedure you should be responsible for paying for are the standard Medicare out-of-pocket costs, which may include:

  • $1,408 for your Part A deductible
  • up to $704 per day for your Part A coinsurance if you’re hospitalized for longer than 60 days
  • $198 for your Part B deductible
  • up to $435 for your Part D deductible
  • other premium, coinsurance, and copayment costs, depending on your plan

Compared to other bariatric surgery procedures, gastric bypass surgery may even be the most cost-effective option for Medicare beneficiaries. In another study from 2017, researchers found that another popular bariatric procedure called gastric band surgery had a high rate of reoperation in Medicare patients, leading to a higher cost for both Medicare and Medicare beneficiaries.

Medicare beneficiaries have a wide variety of plan options to choose from when they enroll in Medicare. If you plan to undergo gastric bypass surgery under Medicare, it’s important to understand what your plan will and will not cover.

Below, you will find details of what each Medicare part covers for gastric bypass surgery.

Part A

Medicare Part A covers any hospital services you need for gastric bypass surgery. This includes the hospital stay for your surgery, as well as any medical services you receive while in the hospital, including nursing care, doctors’ care, and medications.

Part B

Medicare Part B covers any medical services you require for your gastric bypass surgery. This includes any necessary doctor and specialist visits you may need both before and after your surgery. It also includes laboratory tests, certain medications, and any durable medical equipment you may need during or after the procedure.

Part C

Medicare Part C covers everything you would be covered for under Medicare Part A and Medicare Part B. However, most Medicare Part C plans have their own set of coverage rules when it comes to providers. It’s important to make sure that you are seeking services from the approved providers in your network.

In addition, some Advantage plans also offer additional coverage related to your surgery, such as prescription drugs.

Part D

Medicare Part D helps cover any prescription drugs you may need for your gastric bypass surgery. This may include any pain medication you need after the surgery or other medications related to your recovery.

Medigap

Medigap can help cover some of the out-of-pocket costs associated with your gastric bypass surgery. These costs may include deductibles, coinsurance, and copayment amounts for your hospital stay, doctor’s visits, or even excess charges.

A gastric bypass procedure involves two primary components that change the way your digestive tract is routed.

  • The first part of gastric bypass involves sectioning off the top of the stomach. This is done by creating a small pouch at the top of the stomach that is roughly one ounce in volume.
  • The second part of gastric bypass involves dividing the small intestine into two parts. First, the bottom portion of the divided small intestine is connected to the new stomach pouch. Then, the top portion of the divided small intestine is reconnected further down the bottom portion of the small intestine.

There are two types of gastric bypass surgery: open gastric bypass and laparoscopic gastric bypass. Open gastric bypass surgery is performed using a large incision in the abdomen and is typically invasive. Laparoscopic gastric bypass surgery is performed using a laparoscope and is typically much less invasive.

The entire gastric bypass procedure creates a “bypass” of the normal functions of the digestive system, which greatly decreases the amount of food a person can eat. In turn, this decreases caloric intake, as well as the absorption of nutrients. The decreased intake and absorption of foods from gastric bypass contribute to long-term weight loss.

According to the research, gastric bypass is known as the most effective surgery for long-term weight loss. However, it is not for everyone and is generally used only for individuals who have had no other success with alternative weight-loss options. It is also an appropriate option for individuals who have a wide range of comorbidities related to their obesity, such as type 2 diabetes or sleep apnea.

If you and your doctor have decided that gastric bypass surgery is the next step, you’ll want to make sure that your procedure is covered by your Medicare plan. Here are some tips for choosing the best Medicare plan for your needs.

  • Find a plan that covers as many of your services as possible. Original Medicare covers almost all services related to the gastric bypass procedure. However, it does not help with prescription drugs or any additional coverage. If you need more than basic Medicare coverage, consider looking into a Medicare Advantage plan.
  • Choose a plan that limits your out-of-pocket costs. For a lot of Medicare beneficiaries, yearly out of pocket costs can add up, especially when you start adding parts onto your original Medicare plan. Switching to a Medicare Advantage plan instead may help you save money on certain services or equipment for your gastric bypass surgery.
  • Decide what level of provider flexibility you need. Original Medicare generally doesn’t have many restrictions on provider care so long as the provider accepts Medicare assignment. However, many Medicare Advantage HMO and PPO plans have specific rules for which doctors and specialists you can visit, so make sure you know what level of flexibility you need.
  • Make sure you can afford the surgery out-of-pocket costs. There are a variety of costs associated with Medicare, including monthly premiums, yearly deductibles, and more. Some beneficiaries seek coverage for out-of-pocket costs by enrolling in a Medigap plan, while others look for financial assistance programs that can help cover some of these costs.

Gastric bypass surgery is a serious procedure that is undergone by thousands of individuals each year for long-term weight loss. Medicare beneficiaries may be eligible for gastric bypass surgery if they meet certain conditions. When Medicare covers gastric bypass surgery, it covers any diagnostic-, treatment-, and recovery-related services needed.

If you are covered by Medicare and are planning to undergo gastric bypass surgery, it’s important to sit down and make sure that your Medicare plan covers everything you need for a successful procedure.

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