Does Medicaid cover weight-loss surgery?
Last verified:
In most states yes, as a hospital and physician service, with strict criteria: a BMI threshold, related conditions, and a documented supervised weight-loss attempt. Federal rule: state option under medical necessity.
What federal law says
There is no federal Medicaid rule on bariatric surgery. It is covered, where it is covered, as inpatient hospital and physician services subject to the state's medical necessity criteria. Most states cover gastric bypass and sleeve gastrectomy for adults who meet criteria; a few exclude it, and coverage under managed care plans follows the state's policy.
The typical criteria are a body mass index of 40 or more, or 35 or more with a related condition such as type 2 diabetes, sleep apnea or hypertension; a documented supervised weight-loss program of three to six months; psychological evaluation; and an accredited surgical center. Prior authorization is universal.
Follow-up care, nutritional counseling and, later, skin removal surgery are separate questions with separate criteria; skin removal is covered only when the excess skin causes documented medical problems.
Children under 21
Adolescent bariatric surgery can be covered under EPSDT when medically necessary; states apply their own age minimums.
What to ask your state plan
- Start the supervised weight-loss program with your primary care doctor early; it is the criterion most applicants have not met when they first ask.
- Ask the plan for its written bariatric policy; the BMI and documentation rules are spelled out in it.
- Find your state's agency, program name and phone on Medicaid by state.
Related questions
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- Does Medicaid cover over-the-counter medicine?
Common questions
Does Medicaid cover weight-loss surgery?
In most states yes, as a hospital and physician service, with strict criteria: a BMI threshold, related conditions, and a documented supervised weight-loss attempt.
Does Medicaid cover bariatric surgery for children?
Adolescent bariatric surgery can be covered under EPSDT when medically necessary; states apply their own age minimums.
How do I find out whether my state's Medicaid covers bariatric surgery?
Three places. Your plan's member handbook or benefit summary, which lists the covered services and limits; the state Medicaid agency's provider manual for the service, which is public and states the medical-necessity criteria; and the member services line on your card, which can run a coverage check for a specific procedure code. Our state pages list each agency's phone and portal.
Sources
- 42 CFR 440.230 (amount, duration and scope of services)
- medicaid.gov: mandatory and optional Medicaid benefits
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