Our Experts, Your Health

What does insurance cover?

A couple of years ago, the American Medical Association declared obesity a disease.  This move by the AMA is helping to advance treatment and coverage. It is important that we look at obesity as a chronic disease. There is no quick fix or permanent solution. The treatment of obesity or excess weight is life-long. Lifestyle changes are a must, and treatment may also include medications and/or surgery. Surgery is the most successful option; however it still requires commitment to lifelong lifestyle changes.

Lifestyle changes are the foundation that set us up for successful weight management.   While increasing exercise and modifying nutritional habits are often the most obvious changes, it’s also important to look at how you manage stress, your quality of sleep or lack of sleep, your environment, and your personal goals. Stress and poor sleep habits have a strong impact on weight.  Our environment can set us up for failure or success. Having realistic, attainable personal goals can help you stay focused and be successful.

Along with lifestyle changes you may benefit from one of the four weight loss medications: Contrave, Belviq, Qsymia or Saxenda.  Saxenda was recently approved by the FDA and is not to market yet.  It should be available in the coming months. These weight loss drugs do not work alone; they require reduced calorie consumption to be successful.

Lifestyle changes, medication and or surgery are all treatments for obesity and weight, but you might be asking, “How do I access the care I need?”   The Affordable Care Act is helping to increase access for weight loss by requiring most insurance plans to cover screening and counseling for obesity with no patient cost sharing.

When you go in for a physical, your provider will usually check your weight and height and calculate your BMI.  If your BMI is 25 or greater you are considered overweight and if your BMI is 30 or greater you are considered obese.   If your doctor finds that you meet medical guidelines for obesity, he or she might suggest diet and weight reduction counseling or refer you to a specialized program.

Coverage for counseling will vary. Some plans offer telephonic counseling, visits with a health coach, group lifestyle classes, visits with a registered dietitian or even Weight Watchers.  It’s important that you check with your insurance plan regarding the details of weight management/obesity coverage.

Medicare is paying for screening and preventive services for obesity known as Intensive Behavioral Therapy, IBT.  You must have a BMI 30 or greater to qualify for IBT.  It is delivered in 15 minute face to face sessions. There are 14 sessions over six months.

According to the U.S. Preventive Services Task Force, effective weight loss programs involve 12 to 26 group or individual sessions over the course of a year that cover multiple behavioral management techniques.

The good news is that all health plans must cover this intensive behavioral treatment for anyone with obesity but the details of who provides what services is up to individual plans.

Coverage for medications is improving. Some industry sources say that at least 50% of insurance plans are covering weight loss medications.

The Affordable Care Act has increased care for obesity but gaps still remain. Weight loss surgery does not have to be covered. This essential health benefit was mostly left up to the states to decide.  Most states went with benefits that were typical for small group plans, which exclude bariatric surgery. Only 28 out the 50 states cover bariatric surgery as part of the essential health benefit. Surgery is sometimes our best option for the treatment of obesity. We need to advocate for coverage of this service.

Contact your insurance plan to find out what they cover for the treatment of obesity.  If you receive your health plan through your employer, check with your HR department.  If your health plan is self-funded, work with your HR department and advocate for coverage of intensive behavioral treatment, medication, and surgery.  You can make a difference.

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