Losing weight can be a challenging journey, and many individuals find that diet and exercise alone are not enough to achieve their health goals. Medical weight loss programs offer a comprehensive approach, incorporating the expertise of healthcare professionals, behavioral interventions, and sometimes medication or surgery. However, the question of insurance coverage often arises. This article will explore the landscape of medical weight loss programs and delve into the factors that determine insurance coverage.
Understanding Medical Weight Loss
Medical weight loss involves leveraging the expertise, guidance, and support of a physician or a team of healthcare providers for weight loss efforts. This approach often includes behavioral interventions and counseling, which may be provided by a Registered Dietitian or medical provider such as a Physician, Physician Assistant, or Nurse Practitioner. Depending on the individual's needs, it may also include the use of FDA-approved weight loss medication, bariatric surgery, or medical weight loss devices.
The Bariatric and Metabolic Institute emphasizes personalized care and a focus on whole health, recognizing that everyone faces different obstacles to weight loss. Their treatments aim to provide the necessary jump-start to maintain good habits in the long run.
Types of Medical Weight Loss Programs
Medical weight loss programs vary in their intensity and approach. Some common types include:
- Lifestyle Change Programs: These programs, such as the First Step (eight-week) and Focus (15-week) programs, offer weight loss assistance through individual meetings with Registered Dietitians, Exercise Physiologists, and Behavioral Specialists.
- Partial Supplementation Meal Plans: These month-long programs utilize shakes and bars for partial meal replacement, combined with one food-based meal.
- Virtual Group Classes: These one-time or ongoing classes focus on diet, exercise, and behavioral modification.
- HMR (Health Management Resources) Programs: These meal replacement programs involve eating specific foods, such as protein shakes, on a structured meal schedule, with regular support group meetings.
- Personalized Nutrition Counseling: Nutrition professionals work one-on-one to teach the basics of a healthy diet.
- Physician-Supervised Weight-Loss Programs: These programs offer one-on-one treatment options in a medical office, with costs varying depending on the services offered.
- Pre-Packaged Meal Replacement Plans: These medically supervised programs use meal replacement options along with lifestyle modifications and behavior change counseling, transitioning to self-prepared foods for long-term weight loss.
The Role of the Affordable Care Act
The Affordable Care Act (ACA) has played a significant role in expanding access to obesity treatment. Under the ACA, insurance providers are required to cover "obesity screening and counseling." This means that when you go in for a physical, your doctor will usually check your weight and height to figure out your body mass index (BMI). A BMI of 25 or higher is overweight, and a BMI of 30 or more is obese. People who are obese are more likely to get serious health problems such as heart disease, diabetes, and some cancers. Losing weight can lower your chances of getting any of those.
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If your doctor finds that you fit the medical guidelines for obesity, you may get counseling sessions on diet and weight reduction. This may include one-on-one meetings, or you may get weight loss advice and support in a group. The counseling sessions can help you change any unhealthy eating and exercise habits. That, in turn, can help you lose weight and lower the chance of health problems.
However, the ACA does not provide further guidance as to how often you can see your medical provider for counseling or if you can see another provider such as a Registered Dietitian or psychologist. Coverage of these services is going to vary from state-to-state and depend on your particular insurance plan.
Insurance Coverage for Specific Treatments
Insurance coverage for obesity treatment varies depending on your state and insurance plan. Treatment options that may be eligible for reimbursement include:
Behavioral Intervention and Counseling
Changing behaviors around diet and physical activity are important components of any weight loss program, as are ongoing support and accountability. The extent and frequency of counseling sessions can vary significantly depending on the type of provider or provider(s) you see for weight management. Such treatment may be guided by a physician or other medical provider, but could also be provided by a Registered Dietitian or psychologist. Some weight loss programs provide a multidisciplinary approach using a combination of medical providers, dietitians, and/or psychologists.
Despite treatment being foundational to weight management and the proven benefits, health insurance coverage varies. Under the Affordable Care Act, insurance providers are required to cover “obesity screening and counseling”. But there is no further guidance as to how often you can see your medical provider for counseling or if you can see another provider such as a Registered Dietitian or psychologist. Coverage of these services is going to vary from state-to-state and depend on your particular insurance plan. The best way to know what is covered is to check your plan documents or contact your insurance carrier to get more information.
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Weight Loss Medication
When comprehensive behavioral intervention and counseling aren’t enough, FDA-approved weight loss medication may be recommended. These medications are not appropriate for all patients though. Prescription weight loss medication is indicated for persons with a body mass index (BMI) ≥ 27 kg/m2 with a weight-related medical problem or a BMI ≥ 30 kg/m2 who have not responded to more conservative treatment. Additionally, medications are not safe for all persons, so a thorough review of your health history and the current medications you’re taking is important in determining if weight loss medication is right for you.
When it comes to coverage, there is no clear answer to the question “Is weight loss medication covered by insurance?”. It really varies depending on the medication being prescribed and your insurance benefits. Working with a provider who specializes in obesity medicine can help you to work through some of the nuances of insurance coverage as they are familiar with completing prior authorization requests and can discuss alternative options if the medication prescribed is not covered by your plan.
Several FDA-approved prescription medications are available for weight loss, including:
- Phentermine: A stimulant that decreases appetite and boosts energy levels.
- Orlistat (Alli, Xenical): Decreases the amount of fat your body absorbs.
- Contrave (Naltrexone and Bupropion): A combination medication that affects areas of the brain involved in appetite and reward.
- Qsymia (Phentermine and Topiramate): A combination medication that suppresses appetite and increases feelings of fullness.
- Saxenda (Liraglutide): An injectable medication that increases insulin production and regulates blood sugar levels.
- Wegovy (Semaglutide): An injectable medication that mimics a hormone that regulates appetite and food intake.
- Zepbound: An injectable medication that mimics the naturally occurring GIP and GLP-1 hormones released by the intestines into the bloodstream within minutes after we ingest food.
Insurance coverage for prescription weight-loss medications varies by state and by insurance provider.
Bariatric Surgery
Bariatric surgery is the most effective treatment for severe obesity, helping patients lose 20-30% of their initial body weight. Surgery is indicated for persons with a BMI ≥ 35 kg/m2 with a weight-related medical problem or a BMI ≥ 40 kg/m2. Surgical procedures include gastric banding, Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and duodenal switch.
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The decision to pursue bariatric surgery and the most appropriate procedure should be discussed at length with a healthcare provider who specializes in obesity medicine and/or bariatric surgery. Additionally, a long-term commitment to a healthful diet and regular physical activity are necessary for success and safety following bariatric surgery, so finding a team to assist with establishing and maintaining those habits is an important part of the process. Sometimes, certain weight loss medications can be used alongside gastric bypass surgery.
Coverage of bariatric surgery has improved in the last decade as 23 states have a specific health benefit requirement for the coverage of bariatric surgery. Additionally, Medicare and most Medicaid plans cover this treatment option. If you have private health insurance, coverage will depend on your state laws and benefit plan, so it is best to contact your insurance carrier for more information.
Medical Weight Loss Devices
Medical devices used to assist weight loss are relatively new to the treatment toolbox. Just like with medications and bariatric surgery, they are meant to be used in a combination with a reduced-calorie diet, increased physical activity, and behavior changes that promote weight loss and are for patients who have not responded to more conservative treatment approaches.
Some FDA-approved devices for obesity treatment include the following:
- Laparoscopic Gastric Band: An adjustable band placed around the stomach that can be inflated to make the stomach smaller with the intention of decreasing food intake. Insurance that covers bariatric surgery will generally cover the cost of a gastric band.
- Intragastric Balloon: A gas- or liquid-filled balloon swallowed or placed inside the stomach and meant to occupy space to promote a sensation of fullness. Unfortunately the intragastric balloon is not usually covered by health insurance.
- PlenityⓇ: Capsules filled with hydrogel particles and swallowed prior to meals in order to absorb water and occupy space in the stomach, leading to reduced food intake.
Checking Your Insurance Coverage
The best way to determine your insurance coverage for medical weight loss programs is to:
- Check Your Plan Documents: Review your insurance policy documents for information on covered services and exclusions.
- Contact Your Insurance Carrier: Call your insurance company directly to inquire about specific coverage details for weight loss programs, medications, and procedures.
- Consult with Your Healthcare Provider: Discuss your weight loss goals and treatment options with your doctor, who can help you understand what services are likely to be covered by your insurance.
Additional Resources
- Real Appeal®: A weight loss program covered at 100% for eligible UnitedHealthcare health plan members, with no deductibles or co-payments.
- Weight Management Center at Brigham and Women's Hospital: Offers several different plans that can be personalized to your individual weight loss goals and the foods you prefer. Visits are covered by insurance and medications may also be covered by insurance, depending on the individual insurance plan.