Bariatric Surgery Coverage for Weight Loss

You must meet all of the following criteria on the date you request approval for bariatric surgery coverage:

• You must be an active employee or a return-to-work retiree* with five continuous years of Texas Employees Group Benefits Program (GBP) employment with no breaks in GBP coverage.No breaks in coverage can include years of coverage with an HMO in the GBP. The benefit is not available to dependents, retirees not enrolled in active employee benefits, or HMO members, even if they have other insurance that covers bariatric surgery, such as Medicare.
• You must undergo one of the covered bariatric surgical procedures at a Blue Distinction Center for Bariatric Surgery^®.
• You must have at least one other condition considered a co-morbidity, uncontrolled at maximum medical management, and which is generally expected to be reversed or improved by bariatric treatment to include, but not limited to:
  • Diabetes;
  • Hypertension;
  • Sleep apnea;
  • Dyslipidemia;
  • Coronary heart disease;
  • Osteoarthritis; or
  • Any other co-morbidity related to obesity that has not responded to maximum medical management and that is generally expected to be reversed or improved by bariatric treatment.
• You must have been evaluated by a licensed professional counselor, psychologist, or psychiatrist within the 12 months before the request for predetermination of benefits.
• You must have medical records documenting a five-year history of Body Mass Index (BMI) greater than or equal to 40.
• You must have documented active participation in a comprehensive, non-surgical weight reduction program (for example, the BCBSTX weight management program) for at least 12 consecutive months during the 24 months before the date you apply for surgery.
• After surgery, you must provide documentation that you have participated in a medically supervised lifestyle management program for maintaining weight loss and health goals (such as the BCBSTX weight management program) for 12 consecutive months after the date of surgery.

* A return-to-work retiree must enroll in active employee benefits and have five continuous years of active employee coverage as a return-to-work retiree.

The coverage rules for bariatric surgery are different from other HealthSelect services:

• You must pay a $5,000 deductible before HealthSelect coverage starts and before claims are paid by BCBSTX.
• You will be responsible for paying 20% of the allowable amount for the surgery and all related services.
• The most that HealthSelect will pay for bariatric surgery and related services, including prescription drugs, is $13,000 per lifetime. You must pay the remaining costs.
• Your surgery must be performed at a Blue Distinction Center for Bariatric Surgery.

The bariatric surgery benefit is separate from all other HealthSelect benefits. Allowable costs, deductibles, and cost sharing (coinsurance) for bariatric surgery will not count toward other non-bariatric surgery deductibles, out-of-pocket limits, or benefit maximums.

You must follow the plan guidelines for network benefits:

• Obtain a referral from your designated primary care physician (PCP) for specialty care,
• Use providers in the HealthSelect network, and
• Make sure your inpatient admission is preauthorized.

You must pay a $5,000 deductible, then HealthSelect will pay 80% and you will pay 20% of the allowable amount. This means that you must pay the $5,000 bariatric surgery deductible before the plan pays its share. In no event will the plan pay more than $13,000, the lifetime maximum benefit for covered bariatric surgery and related covered services, including prescription drugs. Coverage related to bariatric surgery is limited to HealthSelect network providers only.

Services must be performed in a Blue Distinction Center for Bariatric Surgery. If you receive services from hospital-based providers (for example, anesthesiologists and pathologists) in the Blue Distinction Center for Bariatric Surgery who are not in the HealthSelect network, you will have to pay non-network coinsurance (40%) and you may have to pay charges over the BCBSTX allowable amount. Any non-network charges will be applied to the lifetime maximum benefit of $13,000. Refer to the hospital-based providers list in the Provider Finder for hospitals with network anesthesiologists, pathologists, radiologists, and other specialists.

Complications related to a covered bariatric surgery that occur outside of the bariatric surgery period are covered in the same way as complications related to any other covered service. Complications as a result of a covered service, including covered bariatric surgery, are covered the same way as any other medical condition, and are not subject to the $13,000 bariatric surgery benefit lifetime limit. Complications as a result of non-covered services, such as non-covered bariatric surgery, are not covered.

Your bariatric surgery coverage is good for one month before and 12 months after the date of surgery.

Your bariatric surgery must be preauthorized by and performed in a BCBSTX Blue Distinction Center for Bariatric Surgery to be covered under HealthSelect.

Only one bariatric surgery per lifetime is covered by the plan.

Locate a Blue Distinction Center for Bariatric Surgery where you can have the surgery.

TIP: All Texas hospitals on the "Blue Distinction Centers for Bariatric Surgery" list are available for HealthSelect, which is a point of service (POS) plan.

Your surgery must be preauthorized by a hospital designated as a Blue Distinction Center for Bariatric Surgery; otherwise, coverage will be denied.

Contact bariatric surgery program staff at the hospital for names of physicians who can perform the surgery at the hospital.

Get a referral from your primary care physician (PCP) for the specialist who can perform bariatric surgery at a Blue Distinction Center for Bariatric Surgery.

Make sure the physician is in the HealthSelect network by using your Provider Finder under the Doctors and Hospitals tab or call BCBSTX at (800) 252-8039. You must get a referral from your PCP because the physician performing the surgery is a specialist.

Your physician will discuss with you the additional medical requirements that apply. If you or your physician have questions about the requirements for bariatric surgery coverage, contact BCBSTX at (800) 252-8039.

You must provide a predetermination form  (160 KB) and medical documentation showing that you satisfy all the requirements. Have your physician finish the form and send it to the address on the form. After your predetermination review is complete, you will receive a letter from BCBSTX approving or denying coverage for the surgery.

If coverage is denied, the letter will show which criteria you did not meet, and it will explain your rights to appeal the decision to BCBSTX.

If you are approved by BCBSTX, have your physician preauthorize your inpatient admission through BCBSTX.

Call the appropriate number below for preauthorization:

• In Dallas — (972) 238-7712
• Within Texas — (800) 344-2354
• Outside Texas — (800) 343-0125

For at least 12 consecutive months after the surgery, you must participate in a medically supervised lifestyle management program for maintaining weight loss and health goals. Documentation for the BCBSTX weight management program following surgery will meet this requirement; however, charges for services provided by a licensed doctor or other covered health provider are allowable for up to 12 months after surgery under the bariatric surgery benefit.