Does United Healthcare Alabama Cover Bariatric & Metabolic Surgery?

UHC offers a several different plans either through employer coverage plans or private pay plans. Whether your plan is individual, family, or medicare, you may have coverage for weight loss surgery. Surgical Association of Mobile is in-network for most UHC insurance plans meaning we are able to offer a lower out of pocket expense than providers that United Healthcare labels out of network. Insurance language and policies can be difficult to interpret and navigate for many patients. We have a team of professionals ready to help you better understand your benefits and coverage for weight loss surgery or any procedure we offer here in Mobile, Alabama. Bariatric surgery coverage typically requires that specific insurance guidelines be met and documentation to be detailed. Working with experts, like the team at SAMPA, can help you more easily and confidently move through the process to having your weight loss surgery and successfully gaining insurance coverage.

Will My United Healthcare Insurance Policy Cover Weight Loss Surgery?

We recommend you start evaluating your policy for bariatric coverage by first searching for any written exclusions. In your United Healthcare policy, if obesity treatment and bariatric and metabolic surgery are not covered, there should be a clear section noting exclusion. For all patients pursuing weight loss surgery, we advise you to contact United Healthcare directly for confirmation. While our team is verifying your benefits, we ask to you do the same. You should find a phone number on the reverse of your insurance card to contact UHC directly about your coverage. If your United Healthcare policy is through an employer, you can also reach out to your Human Resources department to speak with the benefits manager. Exclusion of weight loss surgery is not typical, but is does occur in some policies. It is important to verify your bariatric coverage early in the weight loss surgery process to avoid unexpected expenses or hassle down the road.

For procedures like weight loss surgery, there is generally a detailed section laying out exactly what procedures are and are not coverage and what is typically required to qualify for this coverage. Policy guidelines will dictate what steps are required before surgery. It is important to consider that your policy is unique and can vary widely from other plans and groups or ever year to year. You should rely only on information stated in your policy. We invite any patients interested in weight loss surgery to contact both our office and then United Healthcare directly to learn more about coverage for weight loss surgery and to verify your benefits and eligibility. We do this as part of our intake process with every bariatric patient to limit surprises during the process.

How Do I Know How Much Weight Loss Surgery Will Cost?

What a patient will pay, or their financial responsibility, may look very different from one patient to the next. Your out-of-pocket expense for bariatric surgery will depend on your exact benefits and the structure of your insurance policy. You may have copays, coinsurance, individual and family deductibles, and/or and out of pocket max to meet. Plans sometime break expenses down as a percentage insurance will pay versus what the patient will pay. It is also valuable to consider the balance of these numbers can change as your pay medical expenses over the year.

Because you are eligible for coverage for a particular treatment, like bariatric surgery, does not usually indicate that there will be no expense to the patient. Patients who have a coinsurance or deductible will be responsible for paying that amount as stated by their policy. Contacting UHC using the phone number on the back of your insurance card can help you better understand how your financial responsibility is structured. We aim to be clear with you throughout the process regarding your financial commitment, but ask patients to be aware that numbers are estimated and coverage is never guaranteed until a claim is paid. At your first bariatric consultation, the Bariatric Coordinator in our office will take time to meet with you. They will review your benefits and responsibilities with you, including what cost should be expected.

Factors such as deductibles and any set out of pocket max may be impacted with the timing of your surgery scheduling and the ultimate alter your cost for your procedure. The majority of plans will reset with the calendar year. The actual out of pocket expenses for surgery may be lower if you have already paid into your policy for other medical expenses from January to December. It is valuable to keep in mind that the workup process typically requires multiple appointments, pre-operative tests, and clearances to be completed. This all will take time and surgery schedules also tend to become filled towards the end of the calendar year with many patients hoping to take advantage of timing with their policy of holiday scheduling for time off for surgery recovery. It always recommended to start planning several months in advance and beginning the bariatric surgery process early, especially if you would like to take advantage of specific timing.

What Is Required for Insurance to Cover Weight Loss Surgery?

Policy guidelines for bariatric surgery coverage will be slightly different between different insurance plans. Overall, we typically see criteria including the following for bariatric surgery pre-approval. Please remember, specific requirements can be unique to each policy. We always encourage you to verify your coverage as we will.

• A BMI (body mass index) of 40 or greater or a BMI of 35 or greater accompanied by one or more related medical conditions is the typical base criteria. Diseases related to obesity which indicate coverage qualification should be listed in the policy description. Typically they include diseases like type 2 diabetes, hypertension, obstructive sleep apnea (OSA) or others.
• A specific diagnosis on record of morbid or severe obesity is often required to be documented in the patient’s medical record for coverage. This may also be achieved through a letter of attestation from your primary care provider or other specialist in some cases.
• Proof of weight loss attempts may be requested. Some policies are flexible on what satisfies this criteria, while others are very specific. Physician or “medically supervised” weight loss programs are often included in policy guidelines. These may be required over a course of 3, 6, or sometimes 12 months. Others do not include this as a precursor to coverage. In certain circumstances, participation in weight loss programs like Weight Watchers or personal training records will be accepted as part of the patient’s case for bariatric surgery coverage. When this documentation is requested, we find it benefits patients to speak with United Healthcare directly on what documentation will and will not be considered adequate, especially when existing documentation may exist.  If you don’t have a primary care physician, Surgical Association of Mobile will refer you to a physician supervised weight loss program for those who need to meet this requirement.
• Smoking Cessation must be achieved at least eight weeks before surgery in most policies.

What Weight Loss Options Does United Healthcare Alabama Cover?

When UHC has coverage for bariatric surgery, they will typically cover the core bariatric procedures. This includes the gastric sleeve (sleeve gastrectomy), the roux-en-y gastric bypass, and duodenal switch for qualifying patients. The surgeons at Surgical Association of Mobile commonly preform all of these bariatric surgeries and each has proven to be both safe and effective for our patients. Some policies also include coverage for gastric banding procedures like the Lap-band. Some select patients may be good candidates for this procedure. When you have your bariatric consultation, your chosen surgeon will discuss the available procedure options as well as the pros and cons of each with your individual needs and goals in mind.

United Healthcare of Alabama will not cover all weight loss procedures available on the market. Procedures that will not currently qualify for coverage include the intragastric balloon, Lap-Band for lower BMI patients, and obesity treatments currently consider being experimental. This typically includes non-coverage of the Mini Gastric Bypass.

An important notes for patients who had a bariatric procedure but have either not met their goals or have had issues with weight regain, a secondary of revision surgery may be appropriate. Coverage for revision bariatric surgery will vary and often more stringent coverage guidelines must be met. The patient’s medical record must indicate the cause of failure is not a lifestyle consideration, meaning not do to poor eating habits and lack of physical activity after the initial surgery. If you are interested in pursuing a revision weight loss surgery, please contact our office for more details and next steps.

My United Healthcare Plan Excludes Bariatric Surgery… What Are My Options?

Despite the proven success of bariatric surgery over the years in improving patients overall health, not all plans include weight loss surgery in their covered procedures or have very rigid or restrictive guidelines or very high deductibles. For these circumstances, Surgical Association of Mobile has created a competitive self-pay program. Through our bariatric self-pay program, we are able to extend options to those without coverage available or who want to avoid unnecessary restrictions or burdens placed on the process by their insurance carrier.

To further assist patients and remove barriers to bariatric surgery, we work with trusted third party financing providers to aid patients. We welcome you to reach out to our team to discuss your situation and what options we may have. If you have potentially multiple coverage options through your spouse or other available policies, a switch during open enrollment may be beneficial. It may also benefit your to discuss your plans with the benefits department to see if the benefits package through your employer could add bariatric coverage to the plan in the coming year. If you’d like more information to share with your benefits department, please feel free to contact us.

How Do I Contact United Healthcare?

United Healthcare can be contacted by telephone or through their website. Contact numbers may differ based on the type of plan you have. It is best to reference the number on the back of your insurance card to reach the correct department and avoid misinformation.