Have you ever wondered if Medicaid covers tummy tuck surgery? You are not alone. This is one of the most common questions coming from people looking to finance their tummy tuck procedures.
This is not a simple question to answer, as every state has different laws about medical treatment and Medicaid funding. There are some general guidelines that will help you determine whether or not your tummy tuck procedure can be covered by Medicaid.
You may find it hard to access the right information on the internet, so we are here to help you in the following article, providing the best and updated information on does medicaid cover tummy tuck after c section, how to get a tummy tuck paid for by insurance, and how to get a tummy tuck for free.
Is Tummy Tuck Covered By Medicaid
Bodywork and beauty therapy allows us to look and feel our best, but these procedures can often be pricey. Tummy tucks are invasive procedures that are used to improve the look of the abdomen, and if you’re trying to get one, you may be wondering how to get a tummy tuck paid for by insurance.
Over the course of this guide, we’ll cover everything you need to know about how to get a tummy tuck covered by insurance, including the circumstances in which one would be covered. If you’re wondering, “Will Medicaid pay for a tummy tuck?”, we’ll also go into the circumstances in which you can expect it to.
Does Insurance Cover Tummy Tuck?
Tummy tucks are typically considered cosmetic and elective surgeries because they are rarely seen as medically necessary procedures that will either save your life or improve your quality of life. In the vast majority of cases, cosmetic and elective procedures are excluded from health insurance policies.
Will insurance cover a tummy tuck? Probably not. Now, you may be wondering about cosmetic insurance plans, which sound like they might end up paying out for a tummy tuck. However, cosmetic insurance policies are designed to pay for medical expenses that arise after a cosmetic surgery.
For example, if you go in for a tummy tuck and you end up with an infection that needs to be treated ASAP, your cosmetic insurance policy will come into effect and pay out for you. These policies can also pay out if you have problems in the middle of your cosmetic surgery and the doctor needs to do additional work that you’ll be charged for.
In some rare cases, you may find a policy that will pay out for a cosmetic procedure once in a blue moon, but you can bet that these policies will be far more expensive than your typical health insurance policy. The simple fact is that health insurance was not designed to pay for cosmetic procedures like tummy tucks.
Does Medicaid Cover Tummy Tucks?
Even though private insurance typically doesn’t cover tummy tucks, you may be wondering, “Does Medicaid pay for tummy tuck?” Unfortunately, in the vast majority of cases, you can’t expect Medicaid to pay for cosmetic procedures because that’s not what it was made for.
Medicaid was designed to deal with situations that are medically necessary for the patient. For example, if you need to remove a malignant tumor or if you need to get surgery to manage a hernia. Since tummy tucks are typically only cosmetic, they typically won’t be handled by Medicaid.
That being said, it doesn’t mean that it’s impossible to get an abdominoplasty covered by insurance, even if it’s Medicaid. These operations tend to fall into a grey area, so you’ll only ever know if your operation will be covered if you get in touch with your insurers and explain the situation to them.
Of course, it’ll take a little more work than just asking the carrier “Does insurance pay for tummy tuck procedures?” You’ll have to explain why a tummy tuck is a necessary procedure for you and how it will improve your quality of life and potentially even your overall health.
How to Get Medicaid to Cover Tummy Tucks
If you’re wondering how to get a tummy tuck covered by insurance, there are a few rare cases in which Medicaid will pay out. In the vast majority of these cases, there are either extenuating circumstances or the doctors will perform a procedure that’s similar but not identical to a tummy tuck.
If you’re wondering how to get insurance to cover a tummy tuck, you’ll need to prove that you need a medically necessary tummy tuck. Unfortunately, explaining to your insurer that boosted self-esteem will improve your overall health typically won’t fly as an excuse when you’re wondering, “Are tummy tucks covered by insurance?”
One situation in which Medicaid will pay out for your tummy tuck is if the excess skin is causing you back pain because of the additional weight it’s putting on your spine. You may also have incontinence that can be solved by a tummy tuck, but those are essentially the only cases in which a tummy tuck will be performed on its own and covered by your Medicaid.
Can a tummy tuck be covered by insurance in other circumstances? There are times when a doctor may perform a tummy tuck at the same time as another procedure. For example, if you go in for a hernia repair and the doctor performs a tummy tuck at the same time, it may be covered by your Medicaid.
How Much Will a Tummy Tuck Cost Me?
Will insurance pay for a tummy tuck? Most likely not, but that doesn’t necessarily mean that it’s the end of the world. Thankfully, tummy tucks are relatively affordable as far as cosmetic procedures go, and while you don’t want to cheap out when it comes to your health, you won’t have to if you’re willing to save a bit of money.
The average cost of a tummy tuck tends to be between $5000 and $6000, though this can vary dramatically based on where you’re getting the procedure done and the surgeon’s training. For example, some tummy tucks can cost you as much as $12,000 and some can cost as low as $3000.
If this seems a bit steep to you, it’s always possible to arrange a payment plan with the cosmetic clinic that you intend to work with. This will allow you to enjoy a better quality of life after your tummy tuck without having to worry about being on the hook for a huge sum all at once.
As with most medical procedures, you’ll want to take the time to sit down with your doctor and address what you want out of your tummy tuck. If you need a smaller tummy tuck that’s a little less invasive, you may find yourself paying quite a bit less than the average.
Does Medicaid Cover Tummy Tuck After C Section
Medicaid typically covers life-sustaining surgeries such as open-heart procedures and operations to remove malignant cancers.
But what about elective procedures that you schedule in advance to address other less threatening conditions? The answer is a resounding “it depends” because many operations fall into a gray area.
Contact the company administering your plan and request precertification. The response will vary based on three questions, which this article addresses for commonly performed surgeries.
- Is it medically necessary?
- Is it the least costly alternative?
- Does your state institute special rules
Medicaid Cosmetic Surgery
Medicaid rarely covers elective cosmetic surgery because it is not medically necessary in most cases. Cosmetic procedures reshape healthy tissue to alter or improve appearance. You might need to seek out alternatives.
- Cosmetic surgery financing enables affordable monthly payment plans
- Financial help options for surgery could lower related costs
While cosmetic operations might enhance your sense of self-esteem, it does not correct an underlying health problem, which is the key criterion.
Medicaid rarely pays for excess skin removal surgery after significant weight loss surgery because Panniculectomy typically falls into the cosmetic category. Extra epidermis normally does not pose a health risk.
However, your plan could approve skin removal if you can demonstrate the medical necessity. Be prepared to meet these criteria.
- Excess epidermis causes chronic rashes and infections
- You lost more than 100 pounds and maintained a stable weight since
- Bariatric surgery was performed at least twelve months prior
Medicaid will most likely not pay for a tummy tuck except under rare circumstances. This cosmetic surgery typically reshapes otherwise healthy stomach muscles and removes fatty tissue that poses little risk to the patient.
However, a tummy tuck could fall into the medically necessary category if the Abdominoplasty fits one of two narrow criteria.
- Addresses a health condition such as persistent back pain or incontinence
- Performed at the same time as another covered procedure
- Breast reconstruction that requires belly fat
- Hernia repair
Medicaid rarely pays for Liposuction because targeted fat reduction typically falls into the cosmetic surgery category. Reshaping problem areas of your body that do not respond to diet and exercise is not medically necessary.
However, your plan could approve claims for Liposuction if your surgeon can establish that the procedure treats a covered health condition.
- Lipomas: benign fatty tumors
- Gynecomastia: Abnormal enlargement of male breasts
- Lipodystrophy: Selective absence of adipose tissue
- Axillary hyperhidrosis: Excess armpit sweating
Medicaid Plastic Surgery
Medicaid is also more likely to cover plastic surgery because it reconstructs facial and body defects, which is often medically necessary. Choosing the correct words and definitions is especially important with this class of operative procedures.
Consumers often misapply terms, and the industry adds to the confusion by conflating the two disciplines. Free plastic surgery is feasible because, unlike cosmetic procedures, it does more than reshape healthy tissue to enhance appearance: insurance often approves benefits.
Medicaid could pay for plastic surgery for breast reductions. A claim adjuster might look at two main criteria when determining the medical necessity for mammoplasty procedures that remove excess breast fat, glandular tissue, and skin that causes pain, numbness, or irritation.
- Body Mass Index (BMI) is under 35; otherwise, you are too heavy for approval and need to lose weight first
- The symptoms fit into recognized ICD codes for breast reduction approvals
- 9:611.1 postural backaches
- 9:724-5 upper back and neck pain
- 9:695.89 skin fold irritation (intertrigo or dermatitis)
- 9:782.0 ulnar nerve numbness
However, Gynecomastia (breast reduction surgery for men) rarely meets the eligibility requirements because man boobs are seldom large enough to qualify.
Medicaid may pay for plastic surgery to correct a deviated septum because a crooked nasal airway represents a facial defect that impairs breathing. A claims administrator might pre-certify a septoplasty for one of these medically necessary reasons.
- Trauma to the septum leads to deformity
- Reconstruction after surgical nasal excisions: tumors, polyps, or ethmoid bone
- Deviated septum that leads to medical disabilities: recurrent pus-filled sinusitis, deformity or nasal spur with significant airway obstruction, recurrent nose bleeds, facial pain originating from the nasal area, impending septal perforation, or obstructive sleep apnea
Medicaid Weight Loss Surgery
Medicaid typically covers weight loss surgery and related procedures. However, in addition to the three main precertification rules, you must factor in a fourth consideration – is the recommended method experimental.
- Least costly: diet and exercise programs did not shed the excess pounds, and the type of bariatric surgery is not more expensive than alternate treatments
- Medically necessary: Body Mass Index (BMI) of 35 or greater combined with comorbidity: diabetes, high blood pressure, sleep apnea, high cholesterol
- Regional rules: twenty-three states have insurance mandates for weight loss procedures that might apply to public plans
- Not experimental: the Centers for Medicare & Medicaid Services deems specific procedure as unproven and will not honor claims
Given the complex criteria, the patient’s ability to gather the appropriate documentation determines how long Medicaid takes to approve the weight loss surgery. It could take weeks, months, or years depending on how well you and your doctor present the case.
For example, Medicaid is more likely to pay for Lap-Band surgery (Laparoscopic Adjustable Gastric Banding) because this weight loss procedure typically costs less than other treatment alternatives.
Lap-Band surgery’s average cost is about $15,000, which is on the lower end of the price continuum. Since the Centers for Medicare & Medicaid Services deems the procedure non-experimental, it is easier to make a strong case for precertification.
Therefore, it might take Medicaid only a few weeks to approve Lap-Band surgery – provided you document previous diet and exercise regimens, BMI, and comorbidities properly.
On the opposite end of the spectrum, Medicaid is less likely to pay for Gastric Bypass because this weight loss surgery is typically more expensive than other methods.
The average cost of Gastric Bypass is about $24,000, which is much more than other procedures. In this case, a claims adjuster might pre-certify for only the most severely obese patients with a BMI above 40.
Therefore, it could take Medicaid several months to approve gastric bypass surgery because you must prove that other less expensive methods are unsuitable to address your needs – a far more difficult case to make.
Medicaid Joint Replacement
Medicaid is likely to cover elective joint replacement surgeries when medically necessary. Bone-on-bone connections brought on by osteoarthritis (degradation of the cartilage) can cause excruciating pain and rob your ability or use your arms and legs during everyday tasks.
The plan administrator could honor claims when your case meets all three of these conditions.
- Lower cost and less invasive treatments failed to remedy the problem with your joint: Orthotics, Medications (anti-inflammatory and pain management), or physical therapy
- Activities of daily living are impossible given the ongoing joint issue: meal preparation, dressing, driving, or walking
- Medical evidence should verify the diagnosis of advanced osteoarthritis in the joint: severity of discomfort measured against a pain scale, and diagnostic images (bone scans, MRI, CT scan, etc.) showing the severity of the disease
Medicaid is more apt to pay for shoulder replacement surgery when you can show that the ball and socket joint between the scapula and the humerus has deteriorated to the point where you meet all three criteria noted above.
- Prior treatment: a medical doctor prescribed medications and physical therapy, but the shoulder remains dysfunctional
- Activities: you cannot lift and rotate your arm to prepare meals, dress, or drive a car without significant discomfort
- Diagnostic images: show significant arthritis in the ball and socket area that impinges your ability to move your arm freely
Medicaid is more likely to pay for hip replacement surgery when the ball and socket connecting the pelvis and femur degrade enough to meet the three main eligibility rules.
- Prior treatment: a physician prescribed anti-inflammatory drugs and physical therapy to strengthen the hip, but the joint remains unstable and cannot bear weight or pain shoots down one leg
- Activities: you have difficulty bearing weight and cannot walk, climb up and downs stairs, or get into or out of chairs and couches
- Diagnostic images: show severe osteoarthritis in the ball and socket area that hampers the movement of your femur
Medicaid is more likely to pay for knee replacement surgery (arthroplasty) when damage to the conjunction of patella, femur, and tibia causes pain, stiffness, or reduced range of motion.
In addition to medical images and the impact on your daily living activities, a claims adjuster might look more closely at less costly alternatives because of the many options and the procedure’s popularity.
- Non-invasive remedies fail to address the problem
- Modifications in activity including orthotics, braces, rest, and weight loss
- Physical therapy with ice and heat treatments and strengthening exercises
- Medications including oral pain killers and steroid injections
- Other operations for osteoarthritis prove inadequate
- Arthroscopic debridement
- Chondroplasty for cartilage repair
- Osteotomy with axis-correction
The ultimate authority for determining whether Medicaid covers a specific surgical procedure is the company administering your plan. A claim adjuster will issue precertification provided the operation is medically necessary, the least costly alternative, and supported by state rules.
Even a simple surgery for an ingrown toenail, bunion, or hernia is not black or white. Your doctor must establish why the procedure is needed, and the administrator must approve in advance.