Does Blue Cross Blue Shield (BCBS) Florida Blue Cover Bariatric Surgery?
Blue Cross Blue Shield of Florida now known as Florida Blue is our state’s largest health insurance provider with over 50% of Floridians covered under their plans. BCBS offers members a range of plans including Individual & Family, Medicare and Group Health. The Memorial Advanced Surgery providers are in-network for most of these plans. Our team is happy to discuss your benefits and coverage for weight loss surgery and help guide you through what is required for coverage.
Note: In network providers are able to offer a lower out of pocket expense to patients than providers that are out of network by the plan.
Does My BCBS Insurance Policy Cover Weight Loss Surgery?
The most important consideration when evaluating your Florida Blue plan for bariatric surgery is to understand what is covered along with any exclusions in your policy. This can typically be done through a phone call to your insurance provider or by meeting with the benefits manager of your Human Resources Department, if your coverage is through an employer. If bariatric surgery is not a covered benefit of your plan, you will typically find this in the exclusions section of the policy documentation. If weight loss surgery is a covered benefit, there is typically a section dedicated to the exact coverages for bariatric surgery and obesity treatment. It is important to note that coverage can vary between plans and groups. We encourage you to contact both BCBS Florida and our office to find out more and to verify your eligibility.
What Will My Out of Pocket Expenses Be?
Exact coverage for surgery will vary based on your benefits. We encourage patients to call BCBS Florida Blue directly using the phone number on the back of your insurance card or speak to your HR department for policies through your employer. During your office consultation, our Bariatric Coordinator will spend time with you to review your specific benefits and obligations, including what may be required for coverage.
Many plans have deductibles, co-insurances and out of pocket maximums that reset with the calendar year each January 1st. If you are approaching the end of the year, your actual out of pocket expenses for surgery may be lower if you have already paid for medical treatment earlier in the year. Please keep in mind, there may be several required visits prior to surgery being scheduled and it is best to plan several months in advance, even if you plan to take advantage of a paid deductible or met out-of-pocket max for bariatric surgery.
What Are the Requirements for Coverage Of Weight Loss Surgery?
Requirements for surgery coverage will vary between each plan and group’s benefits. These general guidelines for pre-approval of bariatric surgery are standard, but specific requirements may be unique to your policy:
- BMI: A body mass index, or BMI, of 40 or greater or a BMI of 35 or greater with one or more associated medical conditions is typically the first requirement for bariatric surgery candidates. Associated diseases may include diabetes, high blood pressure, severe sleep apnea and more.
- Obesity Diagnosis: Typically, a diagnosis of morbid obesity must be indicated in the patient’s medical records prior to surgery (up to 3 years). Your primary care provider’s attestation as well as dated photographs (digital or hard copy) may be accepted if morbid obesity has not been documented.
- Supervised Weight Loss Program: Depending on the details of your plan, patients may be required to have documentation of physician supervised weight loss attempts over the past 12 months. This may require proof of three, six, nine or 12 months of participation. Some policies do not include this requirement. Other policies may ask for documentation of participation in other non-surgical weight loss programs like support programs such as Jenny Craig, Weight Watchers and more.
- Smoking Cessation: All patients are required to cease smoking at least eight weeks prior to surgery.
What Types of Bariatric Surgery Does BCBS Florida Cover?
Florida Blue covers several bariatric procedures, including the gastric sleeve or sleeve gastrectomy and the gastric bypass. These are the two most popular weight loss surgeries available and are both proven, effective procedures. Some patients will be candidates for Lap-Band surgery, which may also be covered by insurance. Your surgeon will discuss your procedure options and the pros and cons of each with your unique needs and goals in mind at your consultation.
There are some bariatric procedures that are not covered by BCBS of Florida. These include the intragastric balloon, Lap-Band for lower BMI patients, and any surgeries they consider to be experimental, such as Mini Gastric Bypass.
If a primary procedure you underwent in the past was not successful, Florida Blue may cover a revision. Typically, documentation in the medical record is required to show the cause of failure is not a lifestyle consideration. Coverage for revision of bariatric surgery may require additional documentation. If you are interested in pursuing a secondary weight loss surgery, please contact our office.
Bariatric Surgery Is Excluded from My BCBS Plan…What Do I Do?
Despite the success rate and track record of bariatric surgery improving health, not all plans or groups include coverage for weight loss surgery. This does not mean you do not have options! Memorial Advanced Surgery offers competitive self-pay options that may suit your needs, including working with third party financing. If you do not have coverage for surgery, or you have a high deductible or out-of-pocket to be met, we invite you to speak with our team to learn more about how we can assist you. You may also wish to compare plans available through a spouse’s coverage or contact the HR department at your workplace to see if they have incentives for weight loss and bariatric surgery or if changes might be made in the next open enrollment period.
How to Contact Blue Cross Blue Shield of Florida?
Blue Cross Blue Shield of Florida can be contacted via email or telephone. Please be mindful that the contact number may be different depending on the type of plan you have. The best number to reach a representative for assistance is typically listed on the reverse side of your insurance card. For other contact options: https://www.floridablue.com/general/contact-us