How Do I Know if My Health Insurance Plan Covers Weight Loss Surgery?

Once you submit your free insurance check, our team will contact the insurance company to verify your benefits and get details on your coverage for bariatric procedures. You can expect someone from our team to contact you within 3 business days.

Understanding Health Insurance Terms

If you are trying to get a better understanding of what your insurance covers, it can be helpful to know some of the terms that may come up when discussing your plan:

Fully-Insured Vs. Self-Insured
These terms refer to the way your employer provided insurance is set up. A fully-insured plan is the traditional type of employer provided insurance plan, in which your company pays monthly premiums to pay for a predetermined health coverage plan. If you pay for your own insurance through a healthcare marketplace, it is also likely to be fully-insured. If your plan is fully-insured, the benefits are likely determined by a standardized package plan. A self-insured policy is one in which your company is responsible for health care costs, as opposed to the insurance company. In a self-insured policy, your employer decides what is covered. If you have a self-insured policy, you may be able to ask your employer to add bariatric coverage.

Policy Exclusions
A policy exclusion is a medical service that your plan specifically does NOT cover. Some health insurance plans have policy exclusions that prohibit coverage for bariatric surgery. If your employer provided plan has a bariatric policy exclusion, you may be able to ask your company to add bariatric coverage to their offered plans.

Policy Inclusions
A policy inclusion states that certain medical services are covered, but there may be stipulations or prerequisites. For example, your health insurance may only cover bariatric surgery if you first participate in an approved medical weight loss program.

Determining Your Out-of-Pocket Expense for Bariatric Surgery

Your costs will be greatly reduced if you have a health insurance plan that includes coverage for bariatric surgery, but you may still have out-of-pocket costs associated with your care. The amount that you will have to pay will vary based on a number of plan factors, but our team will be able to give you an outline of your costs once you have a consultation appointment and your surgeon determines your treatment plan. Factors that determine your out-of-pocket expenses include:

Deductible
Your deductible is a pre-set amount that you must pay before your insurance company begins to pay for care. For example, if your health insurance plan lists a $500 deductible, that means you must pay for $500 of healthcare services before your insurance begins paying for covered services.

Co-payment (Co-pay)
Your co-pay is a set amount that you must pay for a doctor’s visit. Most plans will have different co-pay amounts for different kinds of visits. If your insurance card lists a $25 co-pay, then you will need to pay at the time of your office visit. Co-pays usually do not count toward your deductible.

Coinsurance
If your health insurance plan includes coinsurance, this is a percentage of healthcare costs that you are responsible for paying AFTER you have met your deductible. For example, if you have coinsurance of 20% (which may be listed as 80/20) and you have a doctor’s bill of $200, then you are responsible for paying $40 of that bill and your insurance will pay $160.

Out-of-pocket maximum
Your out-of-pocket maximum is the highest possible amount that you are responsible for paying in a plan year (check what your insurance defines as a plan year — it may start and end mid-year rather than January to December) . Once the amount you have paid meets the set out-of-pocket maximum, your health insurance company will pay all health care costs for the rest of the plan year. Typically your co-payments, coinsurance, and deductibles will count toward your out-of-pocket maximum. So, if your plan lists an out-of-pocket maximum of $6,000 and you spend that much in the first few months of the plan year, then your insurance will cover 100% of covered services for the remainder of the year.