Does Medicare Cover Weight Loss Programs?
Obesity is a serious public health issue that can lead to many chronic diseases and conditions, such as diabetes, high blood pressure, and heart disease. As such, it is important to take preventive measures, such as screenings and interventions, to combat obesity. These include body mass index (BMI) screening, nutrition counseling, medication, and bariatric surgery. Fortunately, the Affordable Care Act incentivizes states to cover these services with no patient cost sharing.
The ACA’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit provides access to weight loss programs and services for children through Medicaid. However, adults with Medicaid do not have access to these services unless they are dually eligible for Medicare, which also covers obesity screening and therapy through its preventive benefits.
Adults with dual eligibility can receive coverage for weight management through Medicare Part C, which includes the Silver&Fit and SilverSneakers wellness programs that offer fitness classes and gym memberships to beneficiaries. In addition, the ACA has expanded Medicare Advantage plans’ benefits to include coverage for anti-obesity medications. This includes prescription drugs like glucagon-like peptide 1 (GLP-1) agonists, which work by suppressing hunger and increasing satiety. This type of medication has been shown to be particularly effective in helping people lose weight and keep it off.
The federal Centers for Medicare and Medicaid Services (CMS) defines a “clinical treatment model” for obesity that includes nutritional counseling, weight loss medications and bariatric surgery. The clinical treatment model requires a doctor’s recommendation for each of these services to ensure that they are medically necessary. However, the extent to which Medicaid and other private insurance companies cover these services varies by state.
Most fee-for-service Medicaid programs and many managed-care Medicaid programs do not provide coverage for any of the three recommended treatment modalities. Nutritional counselling coverage was slightly more common in managed-care Medicaid plans. Bariatric surgery coverage was most extensive, as 48 states cover this procedure and 23 state benchmark plans and 42 state employee plans do so as well.
It is possible that more states will add coverage for these anti-obesity medications during the current state legislative session as budgets are discussed, Kate McEvoy, executive director of the National Association of Medicaid Directors, told Verywell. Until then, Medicare beneficiaries who want to know more about whether their state Medicaid program covers these prescription drugs can check their plan’s formulary online or call their Medicaid contact number. It is also worth noting that some commercial insurers are starting to cover these medications as a part of their standard coverage, especially in the individual and small-group markets. This could influence how Medicaid and other private insurers follow suit in the future.
