Your Insurance: Medicare, Medicare Advantage, and Medicaid

Coverlipedema.com has successfully obtained Medicare and Medicaid coverage for members. However, the coverage process is far more complicated than that of other commercial and government insurance. We can get them to “cover” directly or on a short appeal, as lipedema surgery is not cosmetic or unproven. However, both plans pay surgeons poorly, and most plastic surgeons are unwilling to perform surgery for such low fees.

Options for Medicare, Medicare Advantage, and Medicaid

Most plastic surgeons treating lipedema are non-participating providers. So, getting Medicare to do a single-case agreement is challenging. We cannot do this with traditional Medicare. Members must pay the surgeon upfront, find a surgeon willing to accept Medicare for payment or switch to a Medicare Advantage plan. Traditional Medicare will reimburse 20 to 25 percent of the surgeon’s fee while fully covering the hospital fees. This could be an option for some members. Finding a surgeon who will accept Medicare poses a great challenge, but a few are worth considering. While we don’t generally recommend Medicare Advantage plans, most cover lipedema surgery. Because of the “right to try” one for a year, you should be able to switch for surgery coverage and then return to traditional Medicare after completing your surgeries without losing your Medi-gap benefit.

Medicaid has similar challenges with payment rates and non-participating surgeons. While we have successfully negotiated coverage for all our Medicaid members, it takes excessive time and effort. But it can be done for members who are willing to work with us.

The New Medicare/Medicaid Process Membership

We have created a new strategy that focuses on dealing with the particular challenges of these insurance plans. Our new approach is called the Medicare/Medicaid Process. It is based on our innovative Coverage Plus Process but with features designed to overcome the unique challenges of Medicare and Medicaid, including additional advocacy to ensure faster coverage. We have hired a dedicated Medicare and Medicaid Ambassador to help members access insurance-friendly plastic surgeons and get their documentation together promptly.

We know that this new membership will lead to many more women having their safe and effective surgeries covered by Medicare and Medicaid in the future.