Health Insurance and Obesity Coverage: What You Need to Know

Obesity medicine is a specialty that focuses on comprehensive medical care for people with heavier weights. Addressing obesity can be beneficial to individuals and contribute to financial relief for the U.S. healthcare system. A 2021 study found that adult obesity in the U.S. accounted for more than $170 billion in added medical costs every year. That’s about $1,900 per U.S. adult.

In the past, the U.S. healthcare system has not prioritized obesity. Before the passage of the Affordable Care Act (ACA) in 2010, insurance companies were able to deny coverage or charge higher premiums to people identified as obese.

Two parts of the ACA offered the potential to reduce health disparities and improve access to weight-loss treatment. They were:

• Medicaid expansion: The ACA allowed Medicaid to cover a wider pool of people. Since 2014, Medicaid has expanded in 38 states and Washington, D.C. Medicaid covers weight-loss surgery in certain patients, which gives more people with low income  access to these services.

• Essential health benefits: Essential health benefits (EHBs) are medical services that must be covered under ACA marketplace plans and all private insurance plans. EHBs include preventive health services for adults, women, and children and are provided without any out-of-pocket cost. Obesity screening and counseling is a preventive service for adults and children.

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These advances in coverage were strong steps in addressing weight stigma and empowering people to get the healthcare they need. Yet, some health insurance plans still do not cover weight-loss treatments.

Here, we explore if and how health insurance covers obesity medicine, including weight-loss surgery — also known as bariatric surgery.

Does health insurance cover obesity treatment?

All health plans are different. Many health plans cover obesity care, including prescription medication and weight-loss surgery. Most cover obesity screenings and counseling. You should consult your summary of benefits and coverage (SBC) for specific details about your plan.

Weight-loss surgery could be accessed far more often in the U.S. Only 1% of eligible people have weight-loss surgery, even though it is the most effective treatment for obesity and diabetes. Having health insurance increases a person’s likelihood of having weight loss-surgery. Among people who have insurance, lower cost-sharing is associated with more weight-loss surgeries.

Being underinsured — which includes having a high-deductible health plan or out-of-pocket costs at 10% or more of your household income — also is associated with a lower likelihood of weight-loss surgery.

Medicare covers several types of obesity treatment.

Original Medicare offers:

• Intensive behavioral therapy for obesity: This program offers BMI screenings, dietary assessment, and behavioral counseling at no cost to enrollees with a body mass index (BMI) of 30 or higher. These services are covered only if they happen in a primary care setting.

• Weight-loss surgery: Medicare covers weight-loss surgery if your doctor determines that it is medically necessary. The covered procedures include gastric bypass, gastric sleeve, and gastric banding. You must have a BMI of at least 35 and another qualifying condition such as diabetes or heart disease. You also must provide documentation that you’ve tried to lose weight through diet and exercise.

Medicare Advantage plans may provide benefits such as gym memberships and fitness programs. One popular fitness program is Silver Sneakers, which is designed for older adults. These plans also may cover weight-loss surgery.

Medicaid and the Children’s Health Insurance Program (CHIP) cover services such as BMI screenings, nutrition education, and behavioral counseling. Medicaid covers weight-loss surgery for certain enrollees. Check with your state Medicaid program for specific details.

Most children who receive weight-loss surgery are older teens who have reached a certain level of physical and psychological maturity. Check with your state’s CHIP program for further information.

Tricare is healthcare coverage for uniformed service members, military retirees, and their families. Tricare covers many weight-loss surgeries, including gastric bypass, gastric stapling, and the gastric sleeve.

To qualify for Tricare coverage, members must meet certain conditions. For instance, an eligible person would be 100 pounds over what is considered an ideal weight for their size. Members also must have a chronic condition such as diabetes or hypertension. Tricare does not cover nonsurgical obesity treatment such as dietary control.

What obesity treatments does health insurance cover?

Your health insurance plan may cover a variety of treatments to address the conditions contributing to heavier weight. They may include:

• Prescription medications

• Counseling

• Surgery

Below, we will discuss each kind of intervention.

Prescriptions

There are several prescription medications approved by the U.S. Food and Drug Administration for weight loss. These work in different ways. Often, weight-loss medications are prescribed to people who have chronic conditions related to their heavier weights. Medications often provide optimal results when paired with proper diet and exercise.

Your health plan may cover some or all of the FDA-approved medications. Check with your plan and, specifically, your formulary for a list of covered prescription medications.

Some common prescription medications for weight loss include:

• Orlistat (Xenical): This is one of the most common medications for weight loss. Orlistat is a capsule available by prescription under the brand name Xenical — and as Alli, a lower-dose, over-the-counter brand. Xenical blocks about 30% of the fat you eat, while Alli blocks about 25%.

• Naltrexone/bupropion (Contrave): Contrave is the combination of bupropion, a medication for depression, and naltrexone, which blocks the brain’s reward system.

• Liraglutide (Saxenda): This is a once-daily injection that slows food as it moves through the stomach to make you feel fuller and decrease hunger.

• Phentermine/topiramate (Qsymia): This capsule is an extended-release combination of two medicines: phentermine and topiramate. It affects the brain to decrease appetite and decrease the amount of food you eat, but the way it works is not fully known.

• Phentermine (Adipex-P, many other brand names): This tablet is an appetite suppressant that can be taken only for short periods of time — usually just a few weeks.

Counseling

Counseling for weight loss or weight management usually includes screenings and education.

As mentioned, original Medicare’s intensive behavioral therapy for obesity program offers screenings, dietary assessment, and behavioral counseling to enrollees with a body mass index (BMI) of 30 or higher. These services have no out-of-pocket cost, but are covered only if they happen in a primary care setting.

Medicaid and the Children’s Health Insurance Program (CHIP) cover services such as BMI screenings, nutrition education, and behavioral counseling.

Tricare does not specifically cover counseling services. You may qualify for an exception if counseling is deemed medically necessary.

Surgery

Weight-loss surgery — also known as metabolic or bariatric surgery — is the most effective and enduring treatment for severe obesity, according to the American Society for Metabolic and Bariatric Surgery.

Having insurance increases the chance that an eligible person will be able to have weight-loss surgery. It’s important to check with your insurance plan to determine:

• Covered procedures

• Conditions you must have to qualify for surgery (Also known as inclusion criteria; the list often includes Type 2 diabetes, high blood pressure, obstructive sleep apnea, and gastroesophageal reflux disease or GERD)

• How much you will be expected to pay out of pocket

Can health insurance charge higher premiums or deny coverage for obesity?

The Affordable Care Act prevents health insurance plans from charging you more or denying coverage for a pre-existing condition, including obesity. Before the ACA, some people were charged more or turned down for coverage for having certain conditions.

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Written by:

Sana Khan MBA, MPH

Sana Khan, MBA, MPH, has over 10 years of experience working in the healthcare and finance industry in a variety of capacities. In the past, she has held roles as an analyst and consultant, and she was a former analyst for one of the largest hospital systems in Ohio.

Edited by:

Cindy George, MPH

Cindy George is the senior personal finance editor at GoodRx. She is an endlessly curious health journalist and digital storyteller.

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