Does Your Insurance Have Liposuction Benefits? Don't Look at Who Manages Your Insurance. Let's Look at the Plan Types Instead
Explaining the different plans in this post.
I get many questions about whether certain plans cover liposuction surgery. The questions typically ask, “Does UHC/Aetna/Cigna/BCBS/etc. cover liposuction surgery?”
That’s not a question I can answer because the company that manages your insurance coverage is less important than the type of plan you have.
This gets a little tricky, so let me explain the best I’m able.
The true indicator of whether your plan will cover your liposuction surgery depends mostly on your plan type.
What I describe below is a general overview. Insurance is nuanced, and many exceptions can be made. Also, insurance changes all the time. The information below is a general rule of thumb.
Insurance is split into two major types of plans: Government and Private.
Government Plans:
In the US, the six major government programs are Medicare, Medicaid, the State Children's Health Insurance Program (SCHIP), the Department of Defense TRICARE and TRICARE for Life programs (DOD TRICARE), the Veterans Health Administration (VHA) program, and the Indian Health Service (IHS) program.
These plans are state or federally-run and have strict benefits that aren’t flexible.
Medicare: Federal insurance for people over age 65 and disabled persons.
Medicaid: State/regional insurance for low-income people.
Tricare/Tricare for Life/VHA: Insurance for military people.
Indian Health Services: Insurance for Indigenous people.
Military insurance is a whole different type of insurance with different benefits for active and retired military personnel. I am familiar with some general VA rules, but I’m not knowledgeable enough to know the intricacies of these plans. I highly recommend contacting them and requesting benefit information if you have one of these plans.
Medicare/Medicaid
The confusion comes especially with Medicare and Medicaid because insurance companies (UHC, Cigna, Aetna, BCBS, and other regional plans) will administer Medicare and Medicaid.
For instance, you have Medicare, and United Health Care is your Advantage plan; they manage your Medicare dollars, and all expenses/claims run through them. You will still need to get preauthorization. However, they must abide by Medicare rules and regulations. If Medicare doesn’t cover liposuction surgery (and as of this writing, they don’t), then you can’t get lipo regardless of which insurance company is managing your Medicare.
This is also true for Medicaid. Since Medicaid is a state program, it is possible that some states may pass laws in the future to cover liposuction for Lipedema, but I haven’t heard that any state has done this yet.
If you have one of these as your primary insurance, you are less likely to have coverage for liposuction surgery. I have heard of some women who’ve had surgical consults covered under the VA, but otherwise, I haven’t yet heard of anyone getting approved for lipo surgery under one of these government plans. Lipedema surgeons typically will not take Medicare or Medicaid. However, things change all the time, so if you have one of these plans, and are looking at getting liposuction surgery, I always recommend contacting insurance to see if they have benefits under your particular plan.
Private Plans:
Private plans are further categorized into four main types of health insurance plans: HMO, PPO, POS, and EPO. The type of plan determines how you share costs with your insurer.
You can sometimes also choose a coverage level: Bronze, Silver, Gold, or Platinum. High-deductible health plans can include a tax-advantaged Health Savings Account (HSA).
PPO: One of the most common plans in the U.S. A health insurance PPO (Preferred Provider Organization) plan allows members to receive care from both in-network and out-of-network healthcare providers. While in-network providers typically offer lower out-of-pocket costs, PPO plans provide the flexibility to seek care from specialists or facilities outside the network without a referral. These types of plans are reimbursing for liposuction surgery. Depending on the company managing the plan (UHC, BCBS, etc.) and some other varying factors, criteria for surgery and benefit levels will vary.
POS: A health insurance POS (Point of Service) plan combines features of HMO and PPO plans, offering members the flexibility to choose between in-network and out-of-network providers. However, POS plans typically require members to choose a primary care physician and obtain referrals for specialist care, with lower out-of-pocket costs for in-network services. A hybrid of HMO and PPO, you may be able to get liposuction surgery approved through this type of plan.
EPO: A health insurance EPO (Exclusive Provider Organization) plan offers coverage exclusively through a network of healthcare providers, with no coverage for out-of-network services except in emergencies. However, EPO plans typically do not require referrals to see specialists, offering members streamlined access to in-network care without the need for a primary care physician. There is a grey area here if EPOs will approve liposuction surgery out-of-network. My personal insurance is technically an EPO as it has zero coverage for out-of-network providers (although it doesn’t describe itself this way), but they did approve my surgery when I requested an OON exception.
HMO: A health insurance HMO (Health Maintenance Organization) plan requires members to choose a primary care physician (PCP) who coordinates all of their healthcare needs within the HMO network. Referrals from the PCP are typically necessary to see specialists, and out-of-network care is generally not covered except in emergencies. HMO’s such as Kaiser are not currently allowing liposuction surgery reimbursement (Update: I’ve heard through the grapevine that a Kaiser plan-Medicare-allowed a liposuction surgery in California, but I can’t confirm this). This is because they don’t have any in-network surgeons for this type of surgery and don’t have a coverage policy. I’ve also heard (through rumors only!) that providers will tell women they don’t have Lipedema, they have morbid obesity.
This breakdown of plan types is more appropriate when you want to see if your health plan covers liposuction surgery. The best you can do to find out which plan type you have (if you’re unsure) is to call your insurance and ask if they have a coverage policy for Lipedema and Lymphedema treatment.
Take care,
Michelle