Your Insurance: Medicare and Medicaid
Enrollees of both Medicare and Medicaid have had their surgeries covered. The process is different depending on your state and whether you have a managed care plan.
We recommend that all members seeking coverage should join coverlipedema.com before surgery so they can ensure they properly document their disease and function. Coverlipedema.com is structured so there is no extra cost to use our coverage resources from the start because we give those member free access to the claims payment resources.
Only traditional Medicare members can submit claims afterwards for out-of-network surgeons, but in-network hospitals have billed Medicare directly and been reimbursed. Medicaid and Medicare Advantage plan members will need approval for out-of-network surgery.
If you have a Medicare Advantage plan that covers lipedema like Aetna it is possible to get approval in advance and get the plan to contract with your surgeon.
Generally, there are limits to even what a cash based surgeon can charge you for a government program even if they are not participating providers (if they are opted out you can’t submit a claim at all). While there is no fee schedule for lipedema surgery, physician professional fees should be less than $9,000 on the west coast and less than $7,000 in the rest of the country for each code billed for liposuction and less than $4,000 for excisions.
With Medicare and Medicaid plans, coverlipedema.com has a strategy for encouraging plans to provide coverage and fair payment that is backed up with a database of materials that our members can access.
Your Next Step
Learn about choosing your surgeon.