Millions of Americans are overweight and even obese. That means millions of people in the U.S. UU. Here's all you need to know about whether or not your health plan covers various weight-loss treatments and services.
A lot of Americans are overweight these days. In fact, the Centers for Disease Control and Prevention (CDC) estimates that more than two-thirds of adults in the U.S. And more than a third (36.5 percent) are obese. That means that approximately 178 million U.S.
adults are overweight and about 91 million are obese. Children and teens face similar weight problems. According to the latest CDC findings, nearly 10 percent of children between the ages of two and five are obese. Just under 20 percent of children aged six to 11 are obese, and the same can be said for just over 20 percent of children aged 12 to 19. As far as CDC is concerned, adults are overweight if their body mass index (BMI) is 25 or higher.
Are obese if your BMI is 30 or higher. BMI is a measure of a person's body fat based on height and weight. Children and adolescents, on the other hand, are compared with others of the same age and height. If they weigh more than 95 percent of children of the same age, they are obese.
Taken together, it's easy to see why and how, say, 200,000 Americans currently undergo bariatric surgery every year. Often that number takes medication in an attempt to lose weight. Moreover, they turn to nutritional and behavioral counseling. As is often the case, the answer here is that it depends.
In particular, it depends on the type of insurance plan you have. Do you get health coverage through Medicaid or Medicare? Or do you get it through an employer, Obamacare's federal marketplace, or a state marketplace? Some of these health plans are more likely than others to help with these types of costs. And some insurance companies are also more likely than others to help with them. Keep reading to find out everything you need to know about when health insurance covers weight-loss treatments and services and when not.
You'll also learn what types of treatments and services are covered and not covered by different policies. You may be wondering why health insurance would pay even part of the cost of the policyholder's counseling sessions, medications, or weight-loss surgeries. After all, many of these treatments come with amazing price tags. That said, being obese or even being overweight is often expensive as well.
Keep in mind that obesity, especially, can lead to a number of diseases and chronic conditions. The main ones are heart disease, diabetes and cancer. That is not where the impacts of being overweight or obese end. More people with obesity are anxious or depressed or have other mental disorders than people with normal weight.
And according to at least one study, obese adults are 29 percent more likely to say they have no purpose in life than non-obese adults. It is not as easy to put a price on these health problems as it is on specific surgical procedures. However, in general, it is clear that obesity and obesity-related conditions cost Americans and their insurers a lot of money annually. Don't worry if you, your spouse, or a dependent child are overweight or obese and need surgery, medication, or counseling.
You probably won't have to pay everything if you have health insurance. That's because most health plans now cover at least some, if not all, of those weight-loss treatments and services. By the way, you can thank the Affordable Care Act (also known as ACA and Obamacare) for that. The ACA requires all individual, family and small group plans (plans that serve 50 or fewer full-time employees) to pay for basic obesity screening.
It also requires that such plans pay for nutritional counseling if a person qualifies for it. If your health plan covers one type of weight-loss surgery, expect it to cover most or all. In other words, it should cover lap bands, gastric shunts, gastric sleeves and more. Perhaps surprisingly, most health insurance plans cover the costs of weight-loss surgery more than weight-loss drugs.
What are some of the anti-obesity drugs we are talking about here? Belviq is a good example. It helps patients to eat less and feel satisfied with eating smaller amounts of food. Saxenda, a shooter, allegedly offers similar relief. And Xenical prevents some of the fatty calories a person eats from being absorbed in the intestines.
Food and Drug Administration Approved These Five Drugs, Health Insurance Companies Are Reluctant to Cover Them. In fact, about a third of insurers don't cover drugs for obesity. Another third covers them, but with limits or restrictions. Why are you hesitating? One possibility is the bumpy past of the diet and medicine industry.
Specifically, doctors discovered that the popular drug Fen-Phen damaged heart valves in the late 90s. That prompted the FDA to call for its recall. Caroline Apovian, director of Boston University's Center for Nutrition and Weight Control Research, recently told NPR that most of her patients can't afford the former and so go without. Coverage has to happen for the problem of obesity to be addressed, he added.
Like most private health plans, Medicare Part B plans also cover the cost of behavioral counseling sessions that help patients lose weight. However, Medicare Part B only covers this type of counseling if it is received in a doctor's office or other primary care setting. In addition, patients must have a BMI of 30 or more for Medicare to approve coverage. Just make sure your provider accepts the assignment before you schedule your first session.
The allowance means that your doctor or provider accepts the Medicare-approved amount as full payment for covered services. Medicare also covers some weight-loss surgeries. Two common examples are gastric bypass and lap band procedures. Also check your latest Medicare Summary to see if you've met your deductibles.
Focus on your Part A deductible if you are going to be admitted to a hospital for your surgery. Focus on your Part B deductible if it's going to be an outpatient procedure. In either case, you have to meet your deductible before Medicare comes into play to pay for this type of care. And even after you start paying, you may be responsible for certain copayments.
For weight-loss drugs, Medicare drug plans, also known as Medicare Part D, are not required to cover them. However, some do anyway, so check your specific policy to see if it covers or excludes the drug you want to take. Your weight-loss drugs are more likely to be covered if you have a Medicare Advantage, Medigap or MedSup plan. Medicaid often covers counseling and weight-loss surgeries as well.
This differs from state to state. So, you'll need to do some research to find out if your state covers the treatment or service you need. The best thing to do is to contact someone from your state's Medicaid agency for specific information about the weight-loss treatments covered by your plans. They are also at increased risk of stroke, high blood pressure, and Alzheimer's disease.
And they're more likely to suffer from anxiety and depression. However, don't be surprised if you have to meet certain requirements before your insurer agrees to cover this type of care. The most common thing is that your BMI is above a certain number, but there are other possibilities as well. However, it is not unusual for health insurance to refuse to cover these types of drugs.
Not all plans cover all types of surgery. So check your policy or talk to someone at your insurance company before you agree to anything. In addition, you expect to have to meet certain requirements for your insurance company to cover your bariatric surgery. Your BMI may have to be above a particular number, or you may need to show that you have tried other methods of losing weight and haven't tried them.
A restriction linked to the coverage of these treatments and services is that they must be performed in a primary care setting or hospital. And they must be done by a vendor who accepts the assignment. Medicare Part D rarely covers weight-loss drugs. However, if you have a Medical Advantage plan, it may cover these drugs.
The same applies to some Medigap or MedSup plans. As always, review your policy or call your insurance company for more information. The Affordable Care Act requires insurance companies to cover obesity screening and counseling at no cost. However, with other common weight-loss treatments, coverage varies depending on where you live and what health plan you have.
Many health insurance plans don't include weight-loss surgery unless it's personally approved. The approval process depends on your meeting the specific requirements to consider weight-loss surgery necessary. These may include meeting a set body mass index, having sleep apnea, coronary heart disease, or type 2 diabetes. In addition, patients may need to participate in a multidisciplinary preparatory surgical regimen to demonstrate that they have already tried to lose weight and have not been successful in their efforts.
In short, Medicare won't cover most weight-loss programs. That said, Medicare covers preventive services, such as obesity screenings, to help people maintain a healthy weight. Learn more about weight loss programs, weight management and Medicare below. This is because doctors often define obesity as excess body fat, not just excess weight.
If your insurance company offers coverage for a medical device, it will often require documentation showing that other weight-loss treatments have been tried first. Coverage usually varies by state and insurance provider, so if you have a particular diet plan in mind, don't hesitate to call your insurance company. Your health insurance may cover medical expenses, but you may be wondering if health insurance will cover medical weight-loss programs. Another possibility is that people who are prescribed weight-loss medicines may be able to take them for the rest of their lives.
That said, Original Medicare covers preventive weight-loss services, such as behavioral counseling, as long as the beneficiary meets certain criteria. Generally, you'll need to have a BMI of 30 or a BMI of 27 with obesity-related illnesses for weight-loss drugs to be covered. These tables give a brief overview of which weight-loss procedures and programs are covered by insurance and which are not. If your weight affects your health, treatments may include weight management therapy, prescription medications, surgery, or medical devices such as an intragastric balloon.
To navigate the initial stages of weight-loss surgery, it is helpful to understand how and if insurance companies contribute financially. A study shows that the average time from when weight-loss surgery is considered until the procedure is actually performed is 3 years. Original Medicare may offer coverage for obesity, behavioral therapy, medical nutrition therapy, and some bariatric surgery procedures. In addition, the weight control pill, Plenity, is considered a medical device that expands in the stomach, limiting the amount you can eat.