If you or your dependents are living with obesity, choosing the right health insurance policy is vital. Managing existing conditions like diabetes or losing weight with counseling, prescription medications, or bariatric surgery may be your priority. This article will provide information on choosing obesity insurance coverage, including tips for comparing plans. We also dive into protections for pre-existing conditions and answer questions about how weight can affect healthcare costs.
How does obesity affect health insurance?
Obesity rates for adults and children are on the rise worldwide, and the United States is no exception. Health providers use the Body Mass Index (BMI) measurement to screen for obesity. A person's BMI is calculated by dividing weight in kilograms by height in meters.
Typically, BMI ranges and categories for adults over 20 include:
- 18–24.9 healthy weight
- 25–29.9 overweight
- 30+ obesity (including severe obesity)
- 40+ severe obesity
Children and adolescents are still growing and developing, so calculations for this population are slightly different.
Although insurance companies often consider a member’s BMI part of the pre-approval process for weight loss treatments, they cannot discriminate because of a high BMI. Typically, people must have at least a BMI of 35 to qualify for weight loss surgery. However, not all policies cover the same treatments.
Almost all health insurance policies, including commercial policies and Medicare and Medicaid, will cover obesity screenings and nutritional counseling (under preventative care services) at no cost to you.
Can an insurance company deny coverage based on obesity?
The Affordable Care Act prohibits insurance providers from charging higher premiums or denying people access to policies because of obesity. Obesity is considered a pre-existing condition. Insurance companies cannot discriminate against you or your dependents for pre-existing conditions. People who are overweight, obese, or severely obese are eligible for health insurance.
However, if your physician recommends specific treatments for obesity or other medical conditions, insurance may require preauthorization. Insurance will only cover specific procedures, treatments, and medications if you meet medical necessity. You will be required to meet medical necessity criteria like anyone else. Additionally, medical necessity criteria and pre-approval processes vary between companies and even between plans within a company. There is no guarantee an insurance provider will approve a medical pre-authorization request.
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Will obesity increase my healthcare costs?
Obesity is a common and serious health condition affecting more than two in five U.S. adults and over 14 million U.S. children and adolescents. Obese people have higher rates of severe diseases like diabetes, heart disease, high blood pressure, and joint problems. They may also struggle with breathing issues like sleep apnea and asthma.
Chronic conditions increase a person’s overall healthcare costs. For example, a diabetic needing life-saving insulin or a person requiring knee replacement surgery can anticipate out-of-pocket costs like copays, coinsurance, and deductibles. Although obesity does not preclude you from health insurance, it’s essential to realize that medical care like surgery or insulin may require pre-approvals subject to a plan’s benefits and coverage.
Total costs can vary. A plan may deny a prescribed medication in favor of an alternate one on their approved prescription drug list. Additionally, insurance plans may amend or change their prescription drug coverage throughout the year, which could impact your costs and available medications. Companies must provide advance notice if prescription coverage benefits vary.
Not all health insurance plans will cover weight loss treatments like digital apps, Weight Watchers, behavioral therapy, prescription medications, or bariatric surgery. The Affordable Care Act does not require insurers to provide these services, yet many do provide some coverage or reimbursement.
How to compare health insurance policies when living with obesity
If you or a dependent is living with obesity or obesity-related health conditions, choosing the right health insurance plan can be stressful. Taking time to dive deeper into a plan’s details is beneficial. You have the right to receive transparent, understandable material about provider networks, financial responsibilities, specific covered benefits, emergency service coverage, and prescription drug coverage. Some plans may be more tailored to obese individuals and offer more coverage for particular treatments.
Whether comparing employer-based plans or policies on the Health Insurance Marketplace, detailed information should be available on each plan page. Medicaid plans are typically located on state-specific Medicaid websites, while Medicare.gov has a wealth of information for potential Medicare beneficiaries. Insurance plans vary from state to state, which is especially important if you anticipate relocating to another state.
The following are terms you should know when comparing insurance plans.
The Summary of Benefits and Coverage (SBC) provides detailed information about which services the plan covers and how costs are divided. It helps clarify your financial responsibilities and details services included and excluded from coverage. A glossary of terms helps explain language contained in a SBC.
A Provider Network Directory lists doctors, facilities, and other healthcare providers contracted with the plan to provide members medical care. Some plans have strict limitations on where you can access medical care, while other plans offer more choices. One is not necessarily better than the other, but if you have established doctors with whom you want to continue care, look closely at the provider network directory to ensure they are on the list.
A Prescription Drug List, also known as a formulary, provides a list of covered medications, estimated costs, in-network pharmacies, and whether pre-approvals are required. Medication coverage can vary depending on factors such as the type of drug, the route of administration, and generic versus brand-name medications. People should look up their prescription medications when comparing potential policies.
Other financial considerations include monthly premiums, deductibles, copays, coinsurance, and individual and family out-of-pocket maximums.
Use a checklist to compare health insurance policies
A checklist is a great way to stay organized when comparing obesity insurance coverage. The following checklist is a guide and can be adjusted to suit your individual or family’s needs.
|✔️ Name of Insurance and specific plan?
|✔️Monthly Premium cost?
|✔️ Coinsurance rates?
|✔️Annual Deductible amount?
|✔️ Provider network?
|✔️ List any known health conditions for each member covered under the policy?
|✔️ What prescription medications do you currently take?
|✔️ Are these medications on the formulary?
|✔️ Are weight loss medications included in the formulary?
|✔️ Do I need pre-approval for any current or future medications?
|✔️ How much does the plan pay for a ____ medication?
|✔️ What is my estimated cost for _____ medication?
|✔️ Am I limited to certain pharmacies?
|✔️ Will using an in-network mail-order pharmacy lessen my drug costs?
|✔️ Is Bariatric surgery covered?
|✔️ What is the pre-approval process for bariatric surgery?
|✔️ Will insurance cover or reimburse a weight management program or digital app?
|✔️ Do I need a physician referral to get coverage for weight loss programs?
|✔️ Other notes?
Obesity support groups and resources for more information
Obesity is preventable, and it makes sense for insurance companies to offer support for weight loss. Although resources vary between private coverage and state or federal plans, there are also public health initiatives and private companies supporting and promoting healthy weight management for Americans.
In addition to working with a healthcare team, you can take advantage of many reliable educational resources. Joining in-person or online groups with meaningful human connections can improve a person’s journey to better health. Some insurance policies may reimburse costs for programs like Weight Watchers or digital apps like Noom. Other online resources and groups may be available for free.
The following resources provide more information and support for those living with obesity:
My Healthfinder is a website run by the U.S. Office of Disease Prevention and Health Promotion. You can find information on various health topics, including achieving a healthy weight. You can also use their free interactive BMI calculator.
The Obesity Action Coalition supports people living with obesity on their journey to better health. This site offers in-depth information, education, resources and dives into insurance coverage concerns. They also provide support via online community groups.
People living with obesity or obesity-related medical conditions can choose a health insurance plan that fits their budget and family needs. The Affordable Care Act prohibits discrimination toward people with obesity. Taking time to learn the details of each prospective policy can help avoid surprises in the future.
Insurance companies cannot charge higher premiums for obesity. The Affordable Care Act prohibits insurance companies from charging members for pre-existing conditions, including obesity.
Health insurance coverage varies from plan to plan and state to state. Insurance benefits can be complicated. Knowing how to compare plans and where to get detailed information can help you make an informed decision.
Almost all health insurance plans, including commercial policies and Medicare and Medicaid, will cover obesity screenings and nutritional counseling. These services are typically covered under preventative care at no cost to you.
- CDC.gov. Adult obesity facts.
- HHS.gov. Pre-existing conditions.
- Medicaid.gov. Reducing obesity.
- Medicine. The association of obesity with health insurance coverage and demographic characteristics: a statewide cross-sectional study.
- World Health Organization. Obesity and overweight.