What To Know About Medicare And Weight Loss Programs
Original Medicare does not cover most weight loss programs. However, Original Medicare may provide coverage for preventive services. For example, Medicare covers obesity screenings, behavioral counseling, and other health services if a Medicare beneficiary meets the eligibility requirements.
Many Medicare Advantage plans or Medigap plans may help cover the costs of weight loss programs. Some plans may also include weight loss counseling as one of its added benefits.
Losing weight can be a difficult process, both emotionally and physically. Because of this, having solid support is vital for losing excess weight successfully. For many people, this may mean joining a weight loss program. But does Medicare cover weight loss programs?
In short, Medicare will not cover most weight loss programs. That said, Medicare covers preventative services, such as obesity screenings, to help someone maintain a healthy weight. Learn more about weight loss programs, weight management, and Medicare below.
Biliopancreatic Diversion With Duodenal Switch
The duodenal switch procedure starts with a sleeve gastrectomy. Then, the lower intestine is divided, leaving only a few feet of intestine connected to the digestive tract.
This procedure usually results in the greatest weight loss, but patients will likely have frequent and loose bowel movements and gas. Patients will also need to be closely monitored for healthy vitamin, mineral, and protein levels.
In some cases, a doctor or surgeon may recommend that you undergo the sleeve gastrectomy first, then revisit the duodenal switch in 9-12 months.
The duodenal switch often results in 60-80 percent excess weight loss within two years.
Medicare Part B Covers Diabetes Screenings
If your doctor determines that you are at risk for diabetes or diagnoses you with pre-diabetes, youre eligible for up to two diabetes screenings each year.
Risk factors for diabetes and pre-diabetes include:
- High blood pressure
- History of abnormal cholesterol, triglyceride or glucose levels
- History of high blood sugar
Medicare Part B will also cover your diabetes screenings if two or more of the following situations apply to you:
- Age 65 or older
- Family history of diabetes
- History of gestational diabetes or delivery of a baby of more than nine pounds
Medicare covers diabetes screenings in full when they are performed by a health care provider who accepts Medicare assignment.
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Diet Deprivation Can Lead To Overeating
On a psychological level a sense of deprivation kicks in around what we cant have and this turns the forbidden food into the forbidden fruit. What happens next is overeating or binge eating on the very food that we are trying to avoid. After a period of time, a diet is once again taken on to control the overeating or perceived addiction to certain foods and so the cycle continues.
In the end, diets dont help people, they hurt people, but diets draw people in because they provide an illusion of control over what feels uncontrollable, which is ones relationship with food.
Does Medicare Cover Weight Loss Surgery/bariatric Surgery
Medicare Part B covers bariatric surgeries such as gastric bypass surgery and laparoscopic banding surgery . However, you must meet certain criteria. For example, your doctor must determine that Medicare weight-loss surgery is necessary.
Bariatric surgery is a procedure that reduces the amount of food the stomach can hold, effectively forcing you to eat less. However, it is invasive and not recommended for everyone.
Medicare does NOT cover cosmetic surgeries, such as excess skin removal for weight loss surgery.
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State Efforts To Improve Access To Obesity Services
A number of states have efforts underway to improve awareness and use of obesity-related services by Medicaid eligible individuals, including MassHealth’s “Mass in Motion,” Missouri’s PHIT Kids weight management program, and the Texas Medicaid Child Obesity Prevention Pilot. Several states are working with their managed care organizations to implement performance improvement projects focused on body-mass index screening and referral for healthy weight and physical activity counseling.
To share information about state Medicaid and CHIP efforts to improve awareness and effectiveness of obesity-related services, email .
What Obesity Treatments Does Insurance Cover
Obesity affects more than a third of Americans. The frustrating thing about health insurance is that coverage typically pays for the complications of obesity but not for treatments to help offset the extra pounds causing health issues. If your weight is affecting your health, treatments can include weight management therapy, prescription medication, surgery, or medical devices like an intragastric balloon. Unfortunately, coverage for obesity care is pretty inconsistent.
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Theres this perception that, if they offer coverage as a health insurance provider, everyone who needs it is going to show up tomorrow and want this care and its going to be really expensive, says Joe Nadglowski, CEO of the Obesity Action Coalition. So they put all these barriers in front of people. They put higher copays. You have to fail at all these other programs first before you can access some of these therapies. So even if there is coverage, its very rarely easy.
These charts offer a brief overview of which weight loss procedures and programs are covered by insurance, and which arent. Every plan and state is different, so regardless of whats listed below, youll want to check with your providereven if its Medicare or Medicaid obesity coverage.
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Criteria For Weight Loss Surgery Cost Coverage Through Medicaid
In order for Medicaid to completely cover the cost of your surgery as well as the associated visits with your surgeon, you are going to need to meet all of the following criteria.
- You will need to be over the age of 13 if youre a female or over the age of 15 if youre a male.
- Your Body Mass Index must exceed 35 and you must have at least one comorbidity, such as high blood pressure, sleep apnea, high cholesterol, or diabetes.
- If you are below the age of 21, you need to have a Body Mass Index exceeding 40 with at least one of the aforementioned comorbidities.
- You must have a printed letter from your primary care physician recommending the medical necessity of weight loss surgery.
- You need to pass a mental health exam showing that you are capable of adopting the necessary lifestyle changes for weight loss.
- You must be able to provide documentation showing that you have tried to manage your weight and comorbidities using standard treatment, but that those attempts were unsuccessful.
- You must complete a medically supervised program for weight loss spanning 6 months, and you need to show documentation that this weight loss program was attempted within the past 12 months before surgery.
Some people will not qualify for weight loss surgery through Medicaid. If you have any of the following conditions or issues, you will not qualify.
- Long-term use of steroids
- Chronic pancreatitis, inflammatory bowel disease, or pregnancy
- Non-compliance with medical treatments
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 dont owe any costs in these situations. Other types of health plans such as short-term coverage arent 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.
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How To Find Out About Your Coverage
The very first thing you should do if youre seeking obesity treatment is have a conversation with your healthcare provider. Learn about your BMI, any comorbidities, and any medical issues in your family history. Try to get a full picture of your overall health, so you know how to move forward. Being proactive is the best path to prevention, Dr. Musielak says.
Plus, youll need all this information to determine if you need to see a specialist or can work with your primary care physician to treat obesitywhich will have an effect on insurance coverage for obesity treatment.
After you have a full picture of your health, take that information back to your insurance company and ask whats covered and whats not. Your healthcare provider may give you specific insurance billing codes for various treatments. Ask your insurance provider under what criteria coverage would apply. Dont assume you dont have coverage.
Keep in mind, as well, that it can be difficult to find obesity care coverage in your insurance plan. It could show up in employee assistance programs, it could be in wellness coverage, it could be somewhere else. When have this coverage all over the place, people cant find it, Nadglowski says. Reach out to your benefits administrator for assistance.
Why Making Diets Reimbursable By Insurers Makes No Sense
Weight Watchers has a high failure rate because well its a diet. It involves a point and calorie system and you get so many points in a day and as long as you dont go over those points, youre good. But the allotted points per day can often equate to a calorie intake well below the average persons energy needs.
If we arent getting enough fuel for our energy needs, then our body goes into a state of physical deprivation and our bodies turn to muscle for energy, not fat, so weight loss may occur but due to muscle and water loss.
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As a result, our energy gets depleted, the immune system takes a hit and irritability increases because wellwere HUNGRY! Or hangry as one Green Mountain participant likes to call it .
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Are There Any Medicare
Medicare has not formally approved any weight loss programs or fad diets. Speak to your doctor before joining a new program. Here is some information about popular weight loss programs.
Recently, private Medicare Advantage plans have been given the ability to cover more benefits, and dietary programs like this could be one of them. However, it is more common to find Medicare Advantage plans that cover Medicare fitness programs and nutritionists.
Does Medicare Cover Gastric Sleeve Surgery
Medicare does cover gastric sleeve surgery when available in your service area. The level of coverage also depends on whether youre getting care as an inpatient or outpatient. Gastric sleeve surgery removes and separates about 85% of the stomach, and then the remaining gets molded into a tubular shape that cant contain much food or liquid.
Patients lose an average of 65% of extra weight after gastric sleeve surgery, which may be why it was the fastest-growing bariatric surgery in 2019.
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How To Get Medicaid Approval For Weight Loss Surgery
If the Medicaid provided by your state covers bariatric surgery, you must consult your physician. Medicaid accepts coverage when there is a medical need for the surgery. It is vital to have a physician who can share relevant information for the medical necessity of bariatric surgery for the patient. Further, to assess the situation, a physician can recommend the patient to approved surgeons.
Approved surgeons help you understand the surgerys basics and different options you may have. After you make a decision, you need to go through some tests and then consult the Medicaid office for pre-approval of the surgery. The process is time-consuming and requires patience as well as perseverance.Before approval, you may have to attend classes to understand the surgery, nutritional requirements, lifestyle changes, and exercises, which are mandatory post the operation. This ensures that the patient understands all implications of the surgery and whats essential to make it successful.
With necessary provisions, you may get approval from Medicaid. These provisions can further include additional classes or further testing. After approval from Medicaid, your surgeon needs to determine your ability to undergo the procedure. This can include medical preparation, blood work, and X-rays. Finally, the surgery is booked. Hence, you get a step closer to a healthier lifestyle and your weight goals.
Very Low Calorie Diets
For obese members who have been prescribed a very low calorie diet , the following services are considered medically necessary for up to 16 weeks after initiation of the VLCD:
- EKG after 50 lbs of weight loss and
- Lipid profile at the beginning and end of the VLCD program and
- Serum chemistries and liver function tests weekly during the rapid weight loss phase of the VLCD, then every 2 weeks thereafter up to 16 weeks.
Note: VLCDs extending beyond 16 weeks are subject to medical review to determine if additional services are medically necessary.
Notes: Prepackaged food supplements or substitutes and grocery items are generally excluded from coverage under most benefit plans. Diagnostic tests required by, for or as a result of non-covered weight loss programs are not covered. Please check benefit plan descriptions for details.
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The Welcome To Medicare And Yearly Wellness Visits
Medicare beneficiaries are highly encouraged to take advantage of two screenings, both covered 100 percent:
- Welcome to Medicare
- Annual Wellness Visit
The Welcome to Medicare visit is available to all new beneficiaries once during their first 12 months with Medicare. After your first year with Medicare, you qualify for a yearly wellness visit, which is also provided at no cost to you.
Both visits include a variety of metrics . You will also complete a Health Risk Assessment that helps your healthcare provider provide personalized health advice and develop a treatment plan.
Your Welcome to Medicare and annual wellness visits are the perfect time to talk to your doctor about weight goals and healthy lifestyle changes you can make to meet them.
Medicare Part B Covers A Diabetes Prevention Program
Medicare Part B will cover your participation in the Medicare Diabetes Prevention Program if you meet the following set of required conditions:
- You have a BMI of 25 or higher
- Youve never been diagnosed with diabetes or End-Stage Renal Disease
- You havent participated in the Medicare Diabetes Prevention Program before
- You have a hemoglobin A1c test result between 5.7 and 6.4 percent, a fasting plasma glucose of 110 to 125 mg/dL or a 2-hour plasma glucose of 140 to 199 mg/dL within 12 months before attending the first core session of the prevention program
The Diabetes Prevention Program consists of 16 sessions that take place over six months. The sessions include training, tips and strategies for weight loss and managing weight from a behavior coach.
The initial six months of training are followed by six additional months of less intensive follow-up sessions and 12 more months of ongoing maintenance sessions.
Medicare beneficiaries who meet the requirements for the program pay nothing for the service.
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What The Health Insurance Covers A Diet
Diets have very little to do with health and so its the message that this sends that bothers me because it says that this diet is reasonable and necessary per health insurance standards. But dieting behavior is one of the primary contributors to emotional eating and eating disorders which is why I find this disturbing. Not to mention, the failure rate of diets is staggering and Weight Watchers is no exception.
Early on in my career as a fitness professional I would often have the following conversation with newer clients:
Client: I went on Weight Watchers again.
Me: Again? Okay why did you decide to do that?
Client: It enables me to control what I eat so that I can lose weight. It works.
Me: How many times have you been on and off Weight Watchers?
Client: Oh I dont know, Ive lost count over the years, but it helps me to get back on track.
I would hear this often from clients that they were once again going on Weight Watchers and it was rarely the first time they were trying it, but the umpteenth time.
Medicaids Requirement For Weight Loss Surgery
Medicaids requirements for weight loss surgery coverage are a little different as compared to other insurance plans. Typically, this is because Medicaid is unique in who they cover and how they cover their patients.
You need to meet a number of specific requirements in order to qualify for weight loss surgery through Medicaid, and you also need to be free from any medical issues that would prevent you from having surgery. If you pass these two tests, then Medicaid will generally pay for your weight loss surgery.
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Medicare Part B Weight Management Services
Since obesity is classified as a disease, Medicare Part B covers it like any other ailment. It all starts with your Welcome to Medicare annual wellness visit when you first enroll, and it continues with your yearly wellness visits. At your appointments, your doctor should check your height, weight, blood pressure, and BMI all things that can help your doctor diagnose you with obesity and provide proper treatment. These appointments do not require cost-sharing.
If your doctor considers you at risk for obesity, you may be eligible for preventative counseling and even appointments with a nutritionist. Medicare Part B can cover medically necessary obesity counseling and nutrition therapy.
Obesity commonly leads to heart disease. Medicare Part B covers cardiac rehabilitation for those who have had a heart attack, heart failure, or a related surgery.