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Will my bariatric surgery be covered under ObamaCare?

Here's what you need to know...
  • Obamacare provides obesity screening as an essential health benefit
  • All qualified health plans offer obesity screening with no consumer costs
  • Weight control treatment or counseling are required in qualified health plans
  • All plans must offer at least one service from each essential benefit category
  • Bariatric surgery can be an essential health benefit in states that adopted a benchmark that included weight loss surgery as an essential benefit.

Obamacare provides weight control detection and treatment as an essential health benefit. It treats obesity as a disease; weight control is part of the approach to use wellness and preventive medicine to reduce the incidence and expense of long-term, severe illness by early detection and treatment. These are among the vital essential health benefits included in every marketplace plan. Comparison shopping is an effective tool for finding the best match of services, costs, and consumer needs for weight control and obesity treatment. Start comparing health insurance plans now by using our FREE tool above!

Each state had the authority to select a benchmark plan that would provide the baseline for health insurance plans sold in the state marketplace.

Rather than defining services in the state, many states defaulted to healthcare.gov and federal action. The standard is based on the typical coverage in the state or jurisdiction prior to Obamacare for a widely used group or employer plan.

Benchmark Plans

The availability of bariatric surgery as an essential health benefit depended upon the services offered in a state prior to Obamacare. States selected among health plan coverage packages that existed prior to the Affordable Care Act to serve as benchmark plans for their states. These were attempts to establish broadly applied models for the essential health benefits that would be required for all plans. The results were that two types of treatment emerged for obesity that was considered to be a preventable disease. The two options for weight loss are:

  1. surgical weight control
  2. nutritional counseling and therapy

Weight control is an ideal issue for research by comparison shopping. Plans vary in the type of service and extent of consumer contribution required. As a large expense, consumers considering bariatric surgery may find the advantages compelling for using a Health Savings Account and a Silver Plan that offers payment assistance and lower deductibles.

Essential Health Benefits

The Obamacare formulas for essential health benefits came from the choices made by each state government to select a benchmark plan as the model for coverage in calendar years 2014-2016. The process added state requirements and prescription drug information to the benchmark plan to form the state’s required levels of essential health benefits. The levels of coverage in the state’s EHB Benchmarks Plan is the minimum level required in the qualified health plans.

Obamacare provides preventive and wellness services as an essential health benefit.

This includes chronic disease management. Obesity is a disease under Obamacare, and all plans must offer diagnosis and detection as part of the benefits with no additional consumer charges. Drug choices are important to weight loss as many methods use diet and supervised diet techniques.

Obesity and Complications

Obesity contributes to the below-described list of severe health risks. In addition to affecting the individual quality of life, these health conditions cause many health difficulties and require medical care. Obesity is a widespread problem in the US and one which contributes to more serious illnesses. Defined as Body Mass Index greater than 30, bariatric surgery is an indicated treatment at a body mass of 35 or greater. Research has connected obesity to:

  • Type 2 or adult onset diabetes
  • Heart disease including cholesterol related diseases
  • High blood pressure and stroke
  • Cancer risks
  • Disability
  • Nerve damage
  • Amputations
  • Blindness
  • Early death

Bariatric Surgery

Twenty-three states adopted or defaulted to weight loss surgery. These include bariatric or gastric bypass procedures that essentially reduce the size of the stomach to control food intake. Comparison shopping can isolate the plans that offer weight loss surgery options. Consumers can make a thorough search of plans and provisions including pricing and insurance payments. These states offer bariatric surgery as part of the treatment of chronic obesity. In three additional states, the requirement provides bariatric surgery in some but not all plans.

Nutrition, Counseling, and Therapy

The non-surgical approach involves education, counseling, and weight control programs as preferred methods to cause weight loss and manage body mass. In sixteen states rules require coverage and insurance reimbursement for screening, counseling or some form of treatment for obesity. In seven other states, such services exist, and rules relate them to detection and prevention of diabetes. When combined, twenty-three states cover non-surgical preventive services for obesity and diabetes-related obesity.

Preventive Care

Obamacare health plans provide preventive care screenings and examinations. These examinations seek to find early stages of conditions that have an evidence-based potential to become severe diseases. These services include screenings, lab work, and tests. They are not specific to complaints but are based on standard elements such as age, medical history, physical condition and gender.

Health Benefits and Weight Reduction Services

Weight management is a service associated with both prevention and wellness health benefits. Some plans relate it to diabetes prevention and screening.

This essential health benefit can lead to diagnosis and treatment in all Obamacare plans at no charge to consumers.

Diagnosis leads to services options in plans from more than 23 states that include surgical options. In the 23 states that offer gastric bypass surgery, one can use comparison shopping to find appealing combinations of services and insurance contributions. These include Silver plans with Health Savings Accounts and costs reduction subsidies.

Wellness Diet and Basics

Wellness policies promote maintenance of healthy lifestyles in individuals that are symptom-free. Diet and exercise are among the basics or foundation elements for improved wellness. Healthy eating is a powerful education and counseling tools for preventive care and wellness. Detailed counseling and instruction including group and individual counseling can lead to dietary changes that can control disease and prevent further disease. High-risk candidates for Type 2 diabetes can reduce risk and avoid long-term chronic illness.

Bariatric Surgery on State Marketplaces

Comparison shopping can assess the various types of surgeries and the costs and benefits. Overall there does not appear to be a cost saving for the healthcare system when comparing patients who get gastric surgeries with those who do not; however, there is a substantial difference in health outcomes for those who get surgeries. The evidence suggests that the health benefits of substantial weight loss can lead to a more balanced long-term physical wellness and fewer needs for obesity-related treatment. In the individual, bariatric surgery promises to reduce weight and provide a sustained long-term reduction in body mass. It provides a health basis for avoiding complications that come with obesity such as heart disease, and adult-onset diabetes. Start comparing health insurance plans now by entering your zip code in our FREE tool below!

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