UMP Coverage for Obesity Management
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For more information about qualifying for obesity surgery, click on the related links below.
Which surgeries are covered?
Uniform Medical Plan offers a limited benefit for obesity surgery. Because of the high-risk nature of obesity surgery, the plan covers just two surgeries and only in very specific circumstances.
Effective January 1, 2009, UMP covers only the following surgeries for UMP enrollees approved by the UMP Medical Director:
- For enrollees ages 21-64, either the Roux-en-Y surgery or Laparoscopic Adjustable Gastric Banding surgery may be covered. Which surgery an enrollee has is a decision made by the surgeon at the Center of Excellence and the enrollee AFTER the enrollee meets all criteria for coverage.
- For enrollees ages 18-20, only the Laparoscopic Adjustable Gastric Banding surgery is covered by UMP.
Enrollees ages 65 or older should check with Medicare for coverage. If Medicare approves obesity surgery, UMP will pay second after Medicare.
Who will be considered for coverage of obesity surgery?
Because obesity surgery requires dramatic and permanent lifestyle changes, these surgeries are not for everyone. Enrollees first must meet strict criteria to be considered. The list of requirements includes but is not limited to having a body mass index of 40 or higher and having a chronic disease such as diabetes, high cholesterol, or high blood pressure. See "Criteria for Coverage" for complete information.
If you are eligible for the presurgical program, you need to follow a diet and exercise regimen and lose 5 percent of your entrance body weight. The final decision to approve surgery is made by a UMP medical director after all presurgical requirements are met. Once approved, enrollees must use providers and facilities designated as Centers of Excellence by UMP. The decision regarding which obesity surgery you have will be made by you and the surgeon at the Center of Excellence.
Who will not be considered for coverage of obesity surgery?
Enrollees who have had any obesity surgery within the last 10 years or any prior obesity surgery covered by a PEBB health plan are not eligible for coverage.
