Bariatric surgery: what your plan must cover and the 12-month waiting period

It is the bariatric surgery coverage mandate in Puerto Rico. It serves two concrete purposes: knowing the benefit exists and does not depend on the plan’s goodwill, and knowing which limits the plan may legitimately apply to you — preauthorization, a waiting period of up to twelve months, one surgery per lifetime and a documented attempt at dietary treatment first.

Patients with morbid obesity, which the law defines as excess body fat determined by a body mass index (BMI) greater than or equal to 35. The law applies to every public or private health plan in the Commonwealth of Puerto Rico, so the benefit does not depend on whether your plan is government or commercial.

• Body mass index (BMI) greater than or equal to 35, which is how the law defines morbid obesity.Verified against the official source
• Preauthorization from the insurance company, health service organization or health maintenance organization.Verified against the official source
• That the first treatment was dietary and lifestyle change, with the physician documenting the prior dietary plan and the reasons for its failure.Verified against the official source
• Treatment plan approved by a physician specializing in bariatric medicine or bariatric surgery.Verified against the official source

• The patient’s written commitment to comply with treatment, including the psychological protocol, within the treatment plan, which shall also detail the risks, complications and benefits of the surgery and the long-term lifestyle changes.

1. 1

   Step 1: Confirm the number: BMI of 35 or higher

   The law defines morbid obesity as excess body fat determined by a body mass index greater than or equal to 35. That is the threshold the law uses for the benefit, and it is what you cite when a plan demands a higher BMI with no basis in the statute.

2. 2

   Step 2: Know which technique is out

   The definition of bariatric surgery lists four techniques — gastric bypass, adjustable band, intragastric balloon or sleeve gastrectomy — and in the same breath provides: “Intragastric balloon surgery shall not be covered.” It is the most surprising exclusion because it hides inside the definition.

3. 3

   Step 3: Document the dietary attempt; the law requires it

   For preauthorization, the first treatment for morbid obesity must be dietary and lifestyle change. The physician must document the prior dietary plan and the reasons for its failure. They must also specify whether the patient has conditions aggravated by morbid obesity, such as cardiovascular or cardiopulmonary disease, severe diabetes, arthritis and sleep apnea.

4. 4

   Step 4: The waiting period has a ceiling, and an exception

   ASES, insurers, health service organizations and health maintenance organizations may require a waiting period before the benefit is covered, “which shall not exceed 12 months, except when the physician certifies that the patient’s life is at imminent risk.” If the plan gives you a longer wait, the law capped it; and if there is imminent risk certified by the physician, the wait does not apply.

5. 5

   Step 5: One surgery per lifetime

   The insurance policy, public or private, shall cover only one surgery per lifetime in Puerto Rico, if the services are available. It is a limit worth knowing before choosing the technique, not after.

6. 6

   Step 6: Excess skin: the rule and its exception

   Surgeries to remove excess skin — commonly known as skin flaps — shall not be covered, except if the physician certifies that removing the excess skin is necessary because it affects the functioning of a body part. That medical certification is the door the law leaves open.

7. 7

   Step 7: The facility must qualify too

   The law sets requirements for the hospital, not only the patient: Joint Commission accreditation plus one of two bodies — the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery; a Bariatric Program in operation for the last twelve consecutive months; 24/7 availability of an institutional medical team; equipment and instruments for the care of morbidly obese patients; internal ambulance service or a formal contract with a company equipped for that population; and written management protocols, patient selection criteria, post-surgical rehabilitation, support groups, follow-up and patient education. Asking about that accreditation is legitimate.

Preauthorization is requested from the plan. If the plan denies it, review and complaint before the Office of the Insurance Commissioner is the route we cover in the health insurance bill of rights, and the Office of the Patient Advocate is the other door. If what was denied was a medication and not the surgery, that is a different guide.

• Assuming the intragastric balloon is covered because the law names it: the same definition says it will not be.
• Accepting a waiting period longer than twelve months: the law set that ceiling.
• Not requesting the medical certification of imminent risk when it applies: it is the exception to the waiting period.
• Arriving without documented dietary history: the law requires it for preauthorization.
• Believing it applies only to private plans: the law covers every public or private health plan in Puerto Rico.
• Counting on a second surgery: the policy will cover only one per lifetime in Puerto Rico.

These are the government pages this guide is based on.

• Oficina del Comisionado de Seguros (OCS)

  OCS

  bvirtualogp.pr.gov

• Office of the Insurance Commissioner

  OCS

  ocs.pr.gov