Obesity Care & Weight Loss: What’s Covered, and What’s Not?
Key takeaways:
Coverage for weight-loss medications depends on your insurance type. By law, Medicare cannot cover medications prescribed solely for weight loss.
If you’re considering bariatric surgery, most insurance plans require you to meet specific eligibility criteria to qualify for coverage.
To improve your chance of coverage for weight-loss interventions, review your policy, gather necessary documentation, and secure prior authorization.
Access savings on related medications
Table of contents
The U.S. is doing better than it was 20 years ago when it comes to helping people lose weight and fight obesity. For example, in 2024, coverage for weight-loss medications increased to 44% among large employers with 500 or more employees. That’s compared with 41% the previous year. Among the largest employers (20,000 or more employees), coverage rose to 64%, up from 56% in 2023.
In 2013, the American Medical Association recognized obesity as a condition worthy of the full scope of medical care. However, there are still many health insurance plans that don’t cover weight-loss treatments. But there are ways to increase your chances of getting coverage for weight-loss programs and treatments, such as getting prior authorization or appealing denied claims.
What kind of weight-loss treatments do insurers cover?
The Affordable Care Act requires most health insurers to cover obesity screening and counseling. These services are considered preventive care for adults and children. Diet counseling is also available for adults at higher risk for chronic conditions. That means you don’t pay anything out of pocket — even if you haven’t met your deductible — as long as you see an in-network healthcare professional.
Some insurance plans may cover additional services. Examples include nutrition counseling and therapy, medication, and surgery.
Nutrition counseling and therapy
Many insurance plans cover nutrition counseling by a registered dietitian or licensed nutritionist. Health plans may also cover medical nutrition therapy (MNT) for certain conditions, such as diabetes and chronic kidney disease. MNT focuses on using nutrition to manage specific health issues and minimize the risk of complications.
You may need a prescription or referral for nutrition counseling and therapy. There may also be a limit on the number of covered nutrition visits. Check your insurance plan to see what’s covered and the requirements.
Medicare covers obesity screening and behavioral counseling when you have a BMI of 30 or more. Your healthcare professional must also provide counseling in a primary care setting, such as a doctor’s office. Medicaid coverage for nutrition counseling and therapy varies by state. Contact your local Medicaid office or visit your state’s Medicaid website to learn about covered services.
Medication
Sometimes, lifestyle and behavioral changes aren’t enough to help you lose weight. Your healthcare professional may consider prescribing you medication after discussing the risks and benefits with you. Weight-loss medications work in different ways. Some medications may help you feel less hungry or feel full sooner. Others make it harder for your body to absorb fat from the foods you eat.
Commercial health plans may cover the cost of prescription weight-loss medications. Check your plan to find out whether these medications are covered and, if so, which ones are approved. Weight-loss medication coverage may come with restrictions. Prior authorization, step therapy, or specific FDA approval for weight loss may be required.
Got Medicare? While Medicare is not allowed to cover medications taken for weight loss, you may receive coverage if they are approved for another medical condition.
Need diabetes supplies or services? Here’s what Medicare covers.
Medicaid weight-loss medication coverage: Some state programs may cover weight-loss medications for people who meet certain requirements.
Medicare is prohibited from covering weight-loss medications unless they are prescribed for other health reasons. Approved purposes may include lowering the risk of heart attack or stroke. Medicare may expand weight-loss medication coverage if the Treat and Reduce Obesity Act is passed by Congress.
Medicaid coverage for weight-loss medications varies depending on the state in which you reside. Programs that cover weight-loss medications may require prior authorizations and impose quantity restrictions. Check your Medicaid plan for details.
As of 2024, the FDA-approved prescription weight-loss medications for long-term use are:
Qsymia (phentermine / topiramate)
Contrave (naltrexone / bupropion)
Saxenda (liraglutide)
Wegovy (semaglutide)
Zepbound (tirzepatide)
Surgery
Bariatric surgery is a weight-loss option for people with BMIs of 40 and higher. In addition, people with BMIs of 35 and above with serious medical conditions who haven’t had success losing weight with diet and exercise changes are also eligible.
Bariatric surgical procedures change the stomach and small intestine. The surgeries limit food intake and improve metabolism. The most common types of operations are:
Check with your private or employer insurance provider to find out the details of your plan’s coverage. The average cost of bariatric surgery is between $7,400 and $33,000 before insurance coverage. You may be responsible for some or even a large portion of that cost, depending on your policy.
Medicare covers some bariatric surgical procedures, such as gastric bypass, when you meet certain conditions. Check with Medicare and your healthcare professional to get a better understanding of the rules. Forty-nine out of 51 state Medicaid programs include coverage for one or more surgical procedures to treat obesity.
How successful are bariatric surgeries? A study found that people who had gastric bypass surgery had lost an average of 28% of their starting weight after seven years. The average weight loss for people who had gastric band surgery was about 15% of their starting weight. Some weight-loss surgeries are performed using minimally invasive techniques.
How is a person diagnosed as overweight or obese?
The medical community generally defines having obesity and being overweight in adults by body mass index. BMI is a measure based on height and weight. It’s a more sophisticated reading than merely stepping on a scale, but it isn’t foolproof. BMI varies by gender, race, body composition, and other factors. A BMI between 25 and 30 is in the overweight category. A BMI of 30 or higher falls into one of three obesity categories.
An elevated BMI by itself may not trigger insurance coverage for services. A health condition associated with overweight or obesity, such as Type 2 diabetes, may need to be documented. Then, insurers generally cover care for both the excess weight and the co-morbid condition. That’s why it pays to advocate for yourself earlier rather than later.
It’s important to reach out for help, Dr. Scott Kahan tells GoodRx. He’s the director of the National Center for Weight and Wellness and a faculty member at the Johns Hopkins Bloomberg School of Public Health. Those who live in rural areas or prefer a remote connection might try a virtual visit with a healthcare professional.
Another option is the CDC’s National Diabetes Prevention Program (DPP). The service is a lifestyle change and support program for people at risk of Type 2 diabetes. It’s available online and at various locations around the country if you meet the eligibility requirements. Costs vary, but some programs may be free. If the programs in your area have a fee, check with your insurer or employer to see if they’re covered. The National DPP Lifestyle Change Program is free for eligible people covered by Medicare.
“Try to find options that you may not have considered before that may be very valuable” both for treatment and prevention, Kahan said.
What are the health threats associated with obesity?
Since 1990, worldwide adult obesity has more than doubled, and adolescent obesity has quadrupled. Today, more than 2 in 5 adults in America have obesity, according to the Centers for Disease Control and Prevention. But the epidemic is not limited to adults. The CDC reports that around 1 in 5 children and adolescents in the U.S. have obesity, as well.
People who have obesity are at an increased risk for many serious and chronic health conditions. Being overweight or having obesity also raises the risk of premature death.
Obesity has been shown to increase the risk of developing the following health conditions:
High blood pressure (hypertension)
High cholesterol (hyperlipidemia)
Gallbladder conditions
Some types of cancer
Obesity may also worsen these conditions. Many complications from obesity can be reversed or improved with diet and exercise, weight loss, and medical treatment.
How do I get my health insurance to cover weight-loss interventions such as Ozempic?
Below are ways to increase your chances of getting your insurance provider to cover weight-loss treatments:
Review your insurance policy. Check what’s covered before proceeding with any treatment. Find out whether there are policy exclusions, preauthorization requirements, or other restrictions.
Gather documentation. Your plan may require that your BMI be documented by a physician or a physician-supervised nutrition and exercise program. You may also have to provide proof that you’ve tried to lose weight through other medically monitored treatments.
Write a letter advocating for coverage. If you don’t have coverage for the care you need, work with your healthcare professional to write a letter to your insurer advocating for it. The letter should describe the weight-related health problems that make treatment necessary. This includes any difficulty with walking or other activities of daily living, Kahan said.
Get prior authorization. The Obesity Action Coalition (OAC) advises that preapproval is almost always required for weight-loss surgery. However, insurers still deny about 25% of people wanting bariatric surgery three times before giving approval. The OAC offers tips and medical codes you can use when seeking preapproval.
Appeal if you’re denied coverage. The clock starts ticking on your appeal rights from the time you receive a denial, so it’s in your best interest to act quickly. You will likely need to request a letter from your healthcare professional. Sometimes the reason for denial is simply a straightforward coding error. Other times, you may need to appeal a denied preauthorization. In some situations, you may have to contest a label of “experimental procedure” or make a nuanced case that requires advocacy.
Frequently asked questions
Insurance providers may not cover prescription medications used exclusively for weight loss. Companies may not consider the treatment medically necessary. For example, Medicare Part D covers weight-loss medications when they’re prescribed for other FDA-approved indications, such as cardiovascular disease or Type 2 diabetes. Additionally, weight-loss medications can be costly. This can deter insurers from providing coverage.
Most insurance plans won’t cover commercial weight-loss programs that aren’t considered medically necessary. Meal replacement services, dietary supplements, and over-the-counter medications are also likely not covered. Liposuction is typically considered a cosmetic procedure and not covered by insurance, either.
Insurers may cover the cost of body contouring surgery for people who have had bariatric surgery. Significant weight loss is usually required. People with medical issues, wounds, or excessive skin that hinders daily activities after bariatric surgery may also be covered. Qualifications for body contouring surgery may include being at least 18 months past surgery and having lost 100 pounds or more.
The bottom line
Being overweight or obese has serious implications for your health. There are effective treatments available today, including counseling, medication, and surgery. Consult with your healthcare professional to document your BMI. Check your insurance coverage before you try any treatment. And don’t be afraid to advocate for yourself.
Why trust our experts?
References
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