Maintaining a healthy weight is crucial for overall well-being, and EmblemHealth offers various resources to support its members in achieving their weight management goals. This article provides a detailed overview of EmblemHealth's weight loss programs, coverage for weight-loss medications, and additional resources for a successful weight loss journey.
Understanding EmblemHealth's Approach to Weight Management
EmblemHealth emphasizes a holistic approach to weight management, focusing on lifestyle and behavioral changes rather than solely on weight loss. The primary goals of treatment should be to change eating habits and physical activity routines and resolve any comorbid conditions. Interventions should focus on encouraging dietary changes, increasing physical activity, and modifying behaviors, rather than weight loss alone. This approach aligns with recommendations from leading health organizations such as the US Preventive Services Task Force (USPSTF), The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP).
Accessing Wellness Programs Through EmblemHealth
EmblemHealth members can access wellness programs through the myEmblemHealth member portal.
- Sign in to the secure myEmblemHealth member portal.
- Go to the Health and Wellness tab.
- Click “Get Started” in the Wellness Program section.
These programs may include regularly scheduled mindfulness or health education sessions led by Vitality WellSpark health coaches which do not require prior sign-in.
*Offerings vary by plan. This program is not available to all members. Vitality WellSpark’s services do not replace the care you receive from your doctor, and content is not intended to be medical advice.
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BMI: A Key Screening Tool
EmblemHealth recommends annual weight screening for patients ages 2 and over using the Body Mass Index (BMI). BMI is a quick and easy way to determine if a person is overweight or obese. Obesity is defined as having a Body Mass Index (BMI) of 30 or higher; and being overweight is defined as having a BMI of 25 or higher. BMI is calculated from a person’s height and weight. For children and adolescents under the age of 16, you must also plot their BMI on growth charts to determine a BMI percentile ranking, since BMI norms vary with age and gender.
Lifestyle and Behavior Changes for Weight Management
Treating weight issues requires lifestyle and behavior changes that include prioritizing healthy eating and physical activity. Losing weight at a gradual pace of about 1-2 pounds per week is ideal if you want to be successful at keeping the weight off in the long term. Weight loss and weight maintenance are about shifting behavior or lifestyle habits for the long term.
Healthy Eating
Work with your doctor and care team on a healthy eating plan that will help you get the right number of calories you need from your diet. Though calories aren’t the only way to determine a food’s nutrition, tracking them can be a good starting point on your weight loss journey. Everyone has different nutritional needs. Make a habit of eating foods that have a high in nutritional value. AdvantageCare Physicians (ACPNY) nutritionists have outlined a few common nutrition do’s and don’ts, and the below video talks about other ways to ensure a healthy diet.
Physical Activity
Eating healthy should be paired with physical activity. For overall health, aim for at least 30 minutes of moderate physical activity most days of the week. To manage weight, you can increase the time to 60 minutes. Keep in mind that common activities - like walking up and down stairs or pushing a stroller - can count toward physical activity. Once you’ve achieved a healthy weight, it’s important to continue eating healthy and exercising regularly to maintain your weight for the long term.
Helpful Resources and Tools
EmblemHealth provides access to various weight management resources, including tools for medical providers and educational materials for patients. These resources can assist in:
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- Encouraging dietary changes
- Increasing physical activity
- Modifying behaviors
Action Plan
Writing down what you eat and how much you exercise daily can keep you accountable to weight loss or weight maintenance goals. This Healthy Weight Action Plan can help to guide you on your weight loss journey.
Calorie Recommendations
The CDC has put out daily calorie recommendations for people to maintain their weight based on age, gender, and activity level.
Fitness Apps
Physical activity should remain an important part of your routine as well. Here are some apps that provide free or low-cost at-home workouts.
- Strava: If you enjoy being outdoors, Strava is a great way to track your runs, walks, and bikes. The app also lets you follow friends, so you can keep each out accountable on your workouts.
- Nike Training Club: The Nike Training Club app offers a library of at-home workouts. Users can filter by type of workout - from yoga to HIIT classes - as well as time and equipment available.
- ClassPass: Available for a monthly fee, ClassPass offers access to both in-person gym workouts and at-home virtual classes. With more than 2,700 locations across the country, the YMCA is also a great community fitness resource. Click here to find the gym near you.
The Role of Support Systems
A weight loss journey can be difficult, especially if you are not seeing results as quickly as you would like. But, be mindful that even small steps can have big health benefits. The CDC says that weight loss of just 5 to 10 percent of your total body weight can lead to improvements in blood pressure, blood cholesterol, and blood sugars. Talking to friends and family and creating an accountability system may help to make the journey easier. For example, if a friend is hosting a party, you could check in with them before the event to ask about the food options and then plan accordingly. Friends and family can also be there to observe your lifestyle changes and make sure that you are losing weight in a healthy way. It might be helpful to talk with a mental health professional or others with obesity who understand how you feel. Communicating your needs can help you to stay on your weight loss journey without sacrificing fun or social events. The National Heart, Lung, and Blood Institute has a list of tips for how to eat healthy when dining out. For example, consider asking if the restaurant can serve fat-free milk rather than whole milk; or ask for salad dressing and any sauce on a main course to be put on the side. It’s also important to communicate any struggles you may be having. People who are successful in their weight loss journey often rely on support from others to help them through challenging periods. It can also be helpful to go through weight loss with a partner who is also trying to lose weight to help stay motivated.
EmblemHealth Coverage for Weight-Loss Medications: A Shifting Landscape
Coverage for weight-loss medications under EmblemHealth can be complex and subject to change. It's crucial to stay informed about current policies and potential limitations.
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Recent Changes in Coverage
Recently, some city employees covered by EmblemHealth experienced a change in coverage for GLP-1 drugs like Zepbound and Wegovy. These medications, initially added to a list of covered medications under an optional prescription rider, were later removed due to the steep costs associated with them.
- The city never planned to cover these drugs due to the steep costs that would fall on city employees.
- The city will continue covering GLP-1 drugs for patients who use them to treat diabetes, but not weight loss.
The Impact of Coverage Changes
The change in coverage has raised concerns among individuals who have found these medications effective for weight loss and managing food cravings. Without insurance coverage, the high cost of these medications can be a significant barrier.
Alternatives and Considerations
When patients stop taking GLP-1s, either because of a loss of insurance coverage or for other reasons, they often gain back the weight they lost and can experience other side effects such as depression.
Some patients who can’t afford name-brand GLP-1s have opted for so-called "compounded” alternatives, which are typically cheaper. Pharmacies and clinics are allowed to mix ingredients to make their own compounded version of an FDA-approved drug if the FDA declares that there’s a commercial shortage. That rule has been applied in recent years to popular GLP-1 weight-loss medications, although it’s unclear how long the approvals will last.
Safety Concerns Regarding Compounded Drugs
Compounded drugs are not individually reviewed and approved by the FDA, and the agency has cautioned that some patients have had bad reactions to compounded GLP-1s because of incorrect dosing. Some patients even had to be hospitalized.
Navigating Insurance Coverage for Weight Loss Surgery
Insurance coverage for obesity surgery varies according to the insurance carrier. Those that cover bariatric, or weight loss, surgery often limit their coverage to certain types of surgery. Insurance companies that cover bariatric surgery have varying requirements. Some may require medical records documenting that you have medical problems caused by your weight or records of your participation in medically supervised weight loss programs. In fact, many insurers require at least six months’ participation in a supervised weight loss program within two years of your proposed surgery date.
Steps to Take Before Visiting a Surgeon
Prior to visiting our office, please do the following steps:
Call your insurance carrier and make sure your plan provides coverage for weight loss surgery, and that you have covered benefits for morbid obesity surgery. Policies can change daily. Regardless of your insurance carrier, call to check your coverage. Keep in mind that although you may have completed all the necessary steps in order to schedule surgery, your insurance plan may not authorize it.
Write down the name of the person you speak with, including first name, last name, and direct phone number.
Your insurance carrier may request the name of the surgery and the CPT/ICD-9 codes. Insurance companies use the following codes to identify the type of procedure or surgery:
- Lap Gastric Bypass: 43644
- Lap Gastric Sleeve: 43775
- Lap Gastric Banding: 43770
- Diagnosis Code (ICD-10) for Morbid Obesity: E66.01
Your call to the insurance company should be for informational purposes only. Our office initiates the formal insurance authorization process after you meet with the surgeon and schedule your surgery date.
Our surgical scheduler cannot initiate the authorization process until you have a surgery date, even if you have already attended our required information session and scheduled an appointment with the psychologist and nutritionist. If you initiate your surgery authorization process without having seen our surgeon, your insurance company may close your authorization case. When you have a surgery date, it may take another two weeks to two months to obtain approval from your insurance carrier.
Insurance Appeals
In almost all instances in which your insurance plan denies preauthorization for your surgery, you have a right to appeal that denial. Our program would not have submitted you for approval if we did not determine that surgery was medically necessary, so if the insurance plan denies the procedure, we think filing an appeal is justified. Appeals can be filed by you as a plan member, or you can appoint someone to assist you.
Eating Disorder Treatment Coverage with EmblemHealth
If you’re suffering from an eating disorder, it’s crucial to find treatment. However, before enrolling in a treatment program, you need to understand your health insurance policy. While some health care plans cover certain aspects of eating disorder treatment, other plans don’t. And different treatment programs and centers also accept different types of insurance.
What Will Emblem Health Cover?
Through the Emblem plan called ValueOptions, partial coverage is available at in-network outpatient programs. Some types of covered treatments include: [1]
- Pharmacotherapy, or treatment provided through medication
- Nutritional rehabilitation
- Family therapy
- Psychosocial intervention, including different types of talk therapy and education
Emblem Health will cover up to 60 outpatient treatment sessions per year. However, if your treatment plan requires additional visits, you’ll need to pay for them out of pocket. There is also possible coverage for co-occurring conditions, including alcohol or substance abuse, if you receive a dual diagnosis. Additional coverage depends on your specific insurance policy. If you’re unsure about treatment coverage, call an Emblem Health representative.
What does Emblem Health Not Cover?
Emblem eating disorder coverage isn’t available for most inpatient treatments. If you need inpatient treatment, you’ll have to call your policy representative for approval. Emblem also doesn’t usually cover specialty treatment programs or facilities. These rehab centers generally have more exclusive or luxurious amenities and activities. Specialty treatment coverage is available on a case-by-case basis. Start by giving Emblem a call to determine if your policy will cover your specific case.
How to Start the Treatment Process Using Emblem Health
Getting started with the treatment process using Emblem Health is simpler than you think! These four steps will help you begin your journey toward eating disorder recovery:
- Find a program you like. First, you should determine which treatment program would be most effective for your symptoms. Find an in-network treatment center that suits your needs, including location, philosophy, accreditation, and environment.
- Contact Emblem Health. You’ll need to discuss coverage details. Be sure to provide them with as much information as possible, like your desired treatment center and program, to finalize everything. This step will also determine if there’s a copay or self-pay for any part of the treatment.
- Contact the rehab center. At this point, you’ll complete the required application and enrollment process. The facility will then verify your coverage through Emblem Health.
- Start treatment. Once your insurance is verified, the treatment center should contact you with more details. You may also want to coordinate with your designated provider to determine your treatment schedule and other requirements, especially for a residential or PHP program.
Types of Eating Disorder Treatment Programs
While researching your healthcare options for eating disorder treatment, you may also want to look into the different levels of care available. These different levels represent a different intensity of treatment. Which level is best for you depends on the severity of your symptoms. The extent of Emblem eating disorder coverage depends on your policy. Your plan may not cover treatments offered at all of these levels, so make sure to discuss your options with an Emblem representative before moving forward with a specific program.
- Residential/Inpatient Treatment: Residential and inpatient treatment programs are for individuals with severe eating disorder symptoms. They offer the highest level of care, including 24/7 monitoring to help manage unhealthy behaviors. The clinical residences provide a supportive environment conducive to eating disorder recovery. Patients are often considered unstable in some way. Instability might include deteriorating health or co-occurring medical conditions. Depending on your specific policy, Emblem Health may cover inpatient treatment. Talk to a representative to determine if your desired program is approved.
- Partial Hospitalization Programs (PHP): Partial hospitalization programs (PHP) offer less intensive treatment than residential programs. While they don’t need hospitalization, patients receive constant monitoring. Sessions are between 6-8 hours and allow patients to sleep at home instead of the facility. In this case, instability is less severe than in patients that need higher level care. While PHP eating disorder treatment coverage isn’t specified, you can still get in contact with Emblem Health to verify.
- Outpatient & Intensive Outpatient Programs (IOP): Outpatient programs are most effective if you have manageable eating disorder symptoms. This lower level of care doesn’t require hospitalization or constant monitoring. They also offer the most flexibility. Patients maintain their daily routine while still receiving treatment. Five days a week, morning, afternoon, and evening sessions are available. As mentioned above, Emblem Health covers 60 outpatient sessions per year. If you’re unsure about the length of your treatment, clarify the total sessions with your treatment center.
- Virtual Treatment: If your desired treatment center is in a different state, consider a virtual program. In most programs, IOP and PHP treatments are available. This option is ideal if your eating disorder symptoms are manageable and less severe. Treatment is often structured the same way as in-person sessions. The main difference? You’ll attend treatment via video chat. Make sure you have access to a computer and an internet connection. There may be additional stipulations with Emblem virtual treatment coverage. Don’t be afraid to ask your representative questions to clarify the limitations of your policy when it comes to eating disorder treatment coverage. The most important thing is that you’re able to begin your journey to recovery.
Curex Allergy Treatment and Potential EmblemHealth Coverage
Curex provides comprehensive care for those suffering from allergies, asthma and eczema. This includes customized sublingual immunotherapy, at-home concierge allergy testing, and symptom management. While it is difficult to estimate out-of-pocket costs prior to a claim being submitted, our team will work with you to make sure your treatment is as affordable as possible. The average patient responsibility is $200/year and depends on your plan (deductibles, coinsurance, telemedicine benefit).
In addition, Curex accepts HSA and FSA. If you pick an insurance plan, we will bill your insurance for each quarterly visit (required). However, this does not guarantee payment, as your health insurance company may deny payment for any service, even if you are eligible or in-network with us. If your insurance company denies payment, you will be personally and fully responsible for payment after services are rendered, including any co-payment, non-covered portions, deductible amount, or coinsurance that applies.
Curex is unable to provide an accurate estimate of how much your insurance will pay and how much you will be responsible for paying. We encourage you to call the number on the back of your insurance card and ask your member representative about your ‘allergy, asthma, and telemedicine visit’ benefits. Once a claim is submitted, we are unable to take it back. By proceeding, you agree to pay any additional charges that may be incurred that are not covered by your insurance policy.
W8MD Weight Loss and Sleep Centers
If you or your loved ones have GHI Emblem Health insurance and are struggling to lose weight, you may be eligible for free help through your health care plan under the Affordable Care Act. EmblemHealth GHI covers screening for obesity, recommending screening and treating all patients ages 2 and over annually for weight issues/obesity by using the Body Mass Index (BMI). If you are overweight or obese, losing weight can lead to numerous health benefits, such as reducing the risk of heart disease, diabetes, and some cancers. W8MD's New York City offices are in network with EmblemHealth GHI, though not with HIP. All insurances are mandated by the Affordable Care Act to cover screening and treatment for obesity.
Prior Authorization and Managed Care
There must be documented evidence that the patient has previously attempted to lose weight through lifestyle modifications without adequate success. Continued use of Semaglutide must be part of a managed care plan that includes ongoing lifestyle modifications. Lack of Prior Authorization: If prior authorization requirements have not been met, EmblemHealth may refuse coverage for the medication. Patients are encouraged to seek patient assistance programs or discounts to help mitigate costs.