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?
Because of the high-risk nature of obesity surgery, the plan covers just two surgeries and only in very specific circumstances when approved by the UMP medical director:
- For enrollees ages 21-64, UMP covers either the Roux-en-Y surgery or laparoscopic adjustable gastric banding surgery. Which surgery an enrollee has is a decision made by the enrollee and the surgeon at the Center of Excellence where the surgery will take place AFTER the enrollee meets all criteria for coverage.
- For enrollees ages 18-20, UMP covers only the laparoscopic adjustable gastric banding surgery.
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 must first 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 meet the initial criteria for coverage, you will be referred to Accomplish Bariatric Nutrition Services*, which specializes in helping obesity surgery patients achieve safe weight loss before and after surgery. An Accomplish nutritionist will help you lose 5 percent of your verified program entrance weight after you meet the initial criteria for coverage. This weight loss is required before you can be approved by UMP for obesity surgery.
The final decision to approve surgery is made by a UMP medical director after you meet all presurgical requirements. Once approved, you must use providers and facilities designated as Centers of Excellence by UMP.
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.
*The Accomplish enrollment fee is $1,450. UMP does not cover this service and enrollees are responsible for the full program cost. The $1,450 cost does not apply to your UMP deductible or annual out-of-pocket maximum.
