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HEALTH INSURANCE INSIGHTS

A new weight-loss drug called Wegovy has shown promise, but there are questions as to whether health insurance companies will cover the prescription drug.

People who are obese have new hope of losing weight, thanks to a drug called Wegovy. Studies have found that patients who use the medication lose an average of 15% of their body weight when receiving weekly injections of the medicine.

“It’s fantastic,” says Dr. Lloyd Stegemann, a member of the board of directors of the Obesity Action Coalition and the director of metabolic and bariatric surgery at Bay Area Hospital in Corpus Christi, Texas.

He adds that the results from Wegovy “are not yet up to surgery, but they are getting closer in terms of what we’re seeing in terms of surgical weight loss, at least with our simplest procedures.”

But the drug can cost as much as $1,500 a month. So, the question is: Will health insurance companies cover the cost of Wegovy? And do they pick up the tab for other forms of obesity treatment?

Read on to find out about treatments for weight loss covered by insurance.

KEY TAKEAWAYS
  • The Affordable Care Act doesn’t require health plans to cover obesity-related medications or surgeries.
  • Health insurance plans may cover overweight and obesity treatment and drugs, but it depends on the specific plan.
  • If you’re denied weight loss treatments, drugs or procedures, you can appeal it with your health insurance company.
  • Obesity can lead to health problems and medical conditions, including Type 2 diabetes and high blood pressure.

Is obesity covered by insurance?

Insurance coverage for obesity treatment is available, but it can be limited.

As part of the Affordable Care Act, all marketplace health plans and many others must cover preventative obesity screening and counseling at no charge to you. That means you will not owe copays or deductibles or any other costs.

Medicare Part B covers obesity screenings and behavioral counseling if your body mass index (BMI) is 30 or more. BMI is a measure of body fat based on height and weight. To be covered, your primary care doctor or another qualified provider must offer the counseling in a primary care setting, such as a doctor's office.

You will not have to pay for these services, which include a dietary assessment and counseling that focuses on a diet and exercise regimen that will help you lose weight.

Under the Affordable Care Act, health plans aren’t required to cover medications or surgeries used to treat obesity, although some do. Some states also have passed their own laws requiring coverage of various types of obesity treatments. For example, around two dozen states require individual, family and small group plans to cover bariatric surgery.

Health insurance plans that existed before the passage of the Affordable Care Act that have not been significantly changed don’t have to provide these services cost-free. Such plans are characterized as “grandfathered plans.”

In addition, some types of health insurance – such as short-term health plans – aren't required to offer these services.

Stegemann wishes coverage of obesity drugs and surgery was more widespread. He believes the reluctance on the part of many insurance plans to cover these treatments grows out of the erroneous belief that poor personal behavior is the sole source of obesity.

“We have such a better understanding of what causes obesity today certainly than we did even 10 years ago,” he says. “And we know that this is not about fault, it’s about physiology. If we don’t control the physiology, we’re never going to get on top of this obesity epidemic.”

How does obesity affect health insurance?

About 19% of children and 42% of adults are obese, according to the Centers for Disease Control and Prevention. Obesity has been tied to many health conditions, including:

  • Diabetes
  • Heart disease
  • Some types of cancer

All told, obesity costs the health system $147 billion a year, the CDC says.

A 2018 study published in the Journal of Obesity & Weight Loss found that the average percentage of expenditures for health care related to obesity during the years 2010 through 2015 was:

  • 9.21% for commercial insurance
  • 6.86% for Medicare
  • 8.48% for Medicaid
  • 4.74% for patient out-of-pocket spending

Given all these costs, can health insurance companies charge you higher premiums if you’re obese?

Health insurance companies can't charge you more, but your employer can,” Stegemann says.

For instance, some companies will create a program that “basically taxes you for certain bad habits,” he says. You might pay more for health insurance if you’re a smoker or if you are obese.

Such programs aren’t common, but they’re becoming more so, Stegemann says. “We are hearing of more and more of it over the last five years,” he says.

Stegemann believes employers have the right aim in mind, but they’re going about it the wrong way.

“They basically are wanting you to be healthy, but they don't give you the tools to do it,” he says, adding that many plans don’t cover you for things like obesity medications or surgery or even a gym membership.

Does insurance cover weight loss programs?

All health plans that conform to Affordable Care Act standards and Medicare must cover obesity screening and counseling as a form of preventative care at no charge to you. You don’t owe any costs in these situations. Other types of health plans – such as short-term coverage – aren't required to cover this type of care.

In addition, the National Conference of State Legislatures says 16 states require plans to cover additional forms of weight loss programs, including at least some coverage and reimbursement for:

  • Dietary or nutritional screening
  • Counseling and/or therapy for obesity, sometimes including weight loss programs

Another seven states require coverage for nutritional counseling or therapy, but only when the diagnosis or treatment is related to diabetes.

Does insurance cover obesity weight loss drugs?

Some health insurance companies cover obesity drugs, but other insurers balk at covering such medicines.

“Once you go on an obesity medication, you generally have to stay on it for life,“ Stegemann says. “And so it’s a cost concern for them.”

If your doctor prescribes medications for overweight or obesity, contact your health insurance company to find out if it will cover them. You might find the information on your health insurer’s website. Or, you can learn more by calling a customer service representative and asking questions such as:

  • Which medications are covered and for how long?
  • Will I owe a copay?
  • Am I restricted to getting my medicines from specific pharmacies?

As a general rule, Medicare doesn’t cover weight loss medications.

Original Medicare benefits don’t offer coverage for any prescription medications for Medicare recipients except those administered during an inpatient hospital stay or in an outpatient setting. To date, no weight loss medication qualifies under these terms. Medicare Part D prescription drug plans also typically don’t cover weight loss medications.

Does Medicaid cover weight loss pills? No, as with Medicare, weight loss medications aren’t covered.

Stegemann laments that so many patients can’t get their medication costs covered.

“It’s just incredibly frustrating as a treating physician, seeing people come in every single day who have good insurance, but they can’t get the medications that they need to get to the root of the problem, which is their obesity,” he says.

Will insurance cover Wegovy?

Recently, the U.S. Food and Drug Administration approved a new medication that shows great promise in treating obesity. Research has found that a drug called semaglutide — which goes by the brand name Wegovy -- helps people lose an average of 15% of their body weight when they receive weekly injections of the medicine.

Wegovy has generated excitement. People lose an average of three times as much weight on the drug compared to other obesity medication -- and it appears to do so without significant side effects.

“Some people do just as well as surgery on this medication and some don’t do well at all,” Stegemann says. “You’ve got to try it and see if it works, but I’ve seen some pretty impressive results.”

Wegovy is costly, with a month of treatment running between $1,000 and $1,500. That has raised an important question: Will health insurance companies cover Wegovy?

On the one hand, some experts say optimistic insurers will agree to cover the medication since it is simply a higher dose of Ozempic, a diabetes drug that many insurers cover. On the other hand, Medicare doesn’t cover obesity drugs, such as Wegovy, and many private insurers follow Medicare's lead.

Ted Kyle, a registered pharmacist and board member with the Obesity Action Coalition, predicts that some insurers will cover Wegovy.

“The reason that some will cover it is because it's very effective and it improves the health of people who take it, sometimes dramatically,” he says.

However, other plans are likely to deny coverage, Kyle says. Some insurers have “bought into the common, false bias that weight loss should be a DIY effort only,” he says.

Does insurance cover weight loss procedures like bariatric surgery?

Obesity treatment insurance coverage varies when it comes to weight loss surgery. Some health insurance companies don’t cover the cost of weight-loss surgery. But, in other cases, an insurer will foot the bill as long as you meet certain conditions.

For example, the insurer may want you to have a full medical workup. You and your doctor likely will have to make a pre-authorization request for the surgery. The health insurance company also may not approve surgery until you have shown documented proof that you have undergone a physician-supervised weight loss program.

In addition, Stegemann says some insurers charge bariatric deductibles that are separate from the patient's regular deductible. Insurers also may place a cap on the amount of coverage they offer, with the patient on the hook for the remaining costs. Finally, you might have to wait up to a year while you try weight loss programs and counseling before the insurer will allow you to schedule the procedure.

Overall, Stegemann says it’s getting more challenging to meet the criteria necessary to be approved for surgery.

“There's no other area of medicine where people have to jump through as many hoops as they do for bariatric surgery,” he says.

Medicare covers some bariatric surgical procedures, including gastric bypass surgery and laparoscopic banding surgery. But to be approved, you have to meet conditions related to morbid obesity.

Does Medicaid cover weight loss surgery? Yes, Medicaid covers surgery in most states.

How to appeal a health insurance company denial

If your health insurer denies the request for weight loss surgery, you can appeal the decision. You will need to build a strong case that your surgery is medically necessary, however.

The appeals process differs by insurer, so make sure you understand your plan's rules and follow them closely. For example, you may only have one or two months in which to appeal the decision. Also, adhere to the proper appeal process. Many insurers will ask you to start the process by phone before moving to a written appeal.

In Stegemann’s experience, health insurance companies that cover bariatric surgery will pay the claim if the surgery is medically necessary and the patient meets all the criteria. But it all depends on whether the patient’s employer offers bariatric surgery as a benefit in the company health plan.

"In  my experience, if the employee does not have coverage for bariatric surgery, there's nothing they can do to get it covered through their insurance,” he says. “They are left with paying cash in order to have it done."

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