5 Important Things Adults With Obesity Should Know About Health Insurance

If you’re living in a larger body, you may have questions about your insurance coverage. A useful first step is knowing what the term “obesity” means to your doctor and insurance company. According to the National Library of Medicine, a person with a body mass index (BMI) between 30 and 40 has obesity. A BMI over 40 is termed “severe,” or “morbid,” obesity.

Having obesity can increase your risk of other conditions such as Type 2 diabetes, heart disease, and cancer, among others. Living with these conditions often requires costly treatment and medication.

For a little peace of mind, then, here are five key facts to know about health insurance coverage for adults identified as obese.

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1. People with obesity can get health insurance at the same price as everyone else

The Affordable Care Act (ACA) — also known as Obamacare — established the guaranteed issue of major medical insurance. That means that an insurer has no right to refuse you a health policy on the basis of your weight or any pre-existing condition. What’s more: After enrollment, an insurer can’t increase your premiums or cost sharing based on your weight.

All marketplace healthcare plans must cover 10 essential health benefits at no charge. You can use these benefits even before you meet your annual deductible. They include obesity screening and counseling, plus other benefits for conditions that are common in people with a BMI of 30 or more.

Some examples of covered essential benefits are:

• Blood pressure screening

• Cholesterol screening

• Type 2 diabetes screening

• Preventive statin medications for older adults at high risk of heart attack or stroke

Coverage for other obesity-related care and treatments varies by state, insurer, or both. The details of your own plan are included in your policy documents.

If you still have questions, call your insurer to ask about coverage. You may want to ask things like:

• What obesity treatment coverage is offered?

• Are there any requirements to qualify for the treatments? What are they?

• What coverage limits or copays are involved for these treatments?

If you're insured through your job, you could also ask your employer’s benefits administrator.

2. Some older health plans can still legally decline coverage due to obesity

Before the ACA, many insurers considered severe obesity a declinable pre-existing condition. As a result, these insurers refused to issue health insurance policies to people identified as obese.

Some health plans can still discriminate. If you’re enrolled in an individual health plan that you purchased before March 2010, you may not have the ACA's protections or mandated coverage.  The same is true if you're covered by a job-based plan that hasn’t substantially cut benefits or increased enrollee costs since March 2010. These health plans are called grandfathered plans.

You may have a “grandmothered” plan that you purchased between March 2010 and October (or December, in some states) of 2013. These transitional legacy plans also may skirt some ACA protections, but they are being phased out by states in 2022.

Your insurance company may decide to alter your plan so that it complies with ACA rules. If so, you may wish to renew it. Or, you can switch to a marketplace plan during the annual open enrollment period that begins November 1. If your job plan ends on a date outside that period, you qualify for a special enrollment period and can buy marketplace insurance at that time. All marketplace plans include the ACA’s rights and protections.

3. Insurance won’t necessarily cover weight-loss medications

Even though you can get health insurance, that doesn’t mean your plan will cover all obesity-related treatments. Medications, for example, can be hit or miss.

If your private insurance plan does cover weight-loss medications, it might only pay for certain drugs. Or, the ones it covers may still have very high copayments. You may need to get prior authorization for your prescribed medication. Your plan might require you to meet certain conditions, such as having obesity plus another health issue.

Coverage of the appetite-controlling medication Wegovy, for example, depends on your insurer. Nationally, only 33% of people with private insurance have unrestricted access to it. Only 6% of people with marketplace plans have it available to them without restrictions.

As for Medicare, its Part D prescription drug benefit doesn't cover any anti-obesity medication. Bipartisan legislation to change this was introduced in Congress in 2021 but has made no headway.

As of 2017, according to the journal Obesity, only 16 states’ Medicaid programs covered weight-loss medication.

4. You may be able to get weight-loss surgery covered, even by Medicare and Medicaid

Some private insurance plans cover weight-loss (“bariatric”) surgery. They typically impose certain conditions, though. Insurance companies often require you to undergo a physician-monitored 3- to 6- month diet program before approval.

A 2020 study revealed that 75% of private insurance policies call for a pre-surgery psychological screening. For 25% of policies, a licensed mental health provider must evaluate you. Also, some insurers don’t consider the surgery medically necessary unless you have obesity-related ailments or a BMI over 40.

Medicare will cover bariatric surgery for people who meet the qualifications for morbid obesity, if a physician determines the surgery is medically necessary. Gastric bypass, gastric sleeve, and gastric banding are among the options. Outpatient procedures are covered under Part B. If you’re getting admitted to the hospital, Part A benefits apply.

Medicare Advantage coverage details will vary by plan. But, by law, Medicare Advantage plans must cover all the same benefits as original Medicare, even if their rules and out-of-pocket costs differ.

Bariatric surgery became more widespread among uninsured people with Medicaid’s expansion in participating states. Medicaid now covers some form of bariatric surgery in 48 states. But that doesn’t mean that getting approval is easy. A 2022 journal article reported that Medicaid patients have to fulfill an average of 4 requirements before surgery.

5. Behavioral therapy for weight loss may be covered

Private health insurance sometimes covers or defrays the cost of a medical weight-loss program. Such programs often employ nutrition counseling and intensive behavioral therapy (IBT). The goal is to help you focus on changing food and exercise habits. For example, some plans could offer limited nutrition counseling with registered dieticians. Behavioral counseling, medical nutritional therapy, or weight-management counseling might also be covered.

If you’re on Medicare and have a BMI of 30 or more, Part B could cover IBT for you. You pay nothing for this service if your primary care doctor or other qualified primary care practitioner accepts assignment. Unfortunately, this rule makes it hard to access most IBT and nutrition counseling programs.

In some states, Medicaid plans cover obesity counseling and nutritional counseling. Even then, coverage may require:

• A specific comorbid condition (such as diabetes)

• Prior authorization

• Cost sharing

• Access via certain plans

• Annual or lifetime benefit limits

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Written by:

Lora Shinn, MLIS

Lora Shinn is a freelance writer with more than a decade of experience writing about health and personal finance, and has written for outlets such as Prevention, Healthline, The Paper Gown, and The Balance. Topics covered have ranged from medical clowning to creating a healthier home.

Edited by:

Caren Weiner, MSIS

Caren Weiner, MSIS, began her personal finance journalism career in 1986. She worked as a reporter for Money magazine and co-wrote its book-length “Guide to the 1986 Tax Reform Act.” From the beginning, she immersed herself in data on mutual fund total returns and marginal tax rates.

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