Health Insurance

Can Health Insurance Companies Charge People With Obesity Higher Premiums?

Written by Jeanne Dorin McDowell

Published on May 16, 2022

miljko/E+ via Getty Images

Key takeaways:

Under the Affordable Care Act (ACA), health insurance companies can’t deny you coverage or charge you higher premiums on the basis of weight.
The ACA also requires insurers to cover body mass index (BMI) screening and counseling as preventive care.
Coverage of weight-loss surgery, medications, and related care varies from state to state.

More than 4 in 10 American adults are identified as obese. At the same time, for people with larger bodies, health insurance coverage can be inconsistent and sometimes confusing. Guidelines and requirements vary depending on your insurer and the state you live in.

But federal law makes one thing clear: Health insurance companies may not penalize people with pre-existing conditions such as obesity.

Here's more on what people with larger bodies can expect from their health insurance coverage.

How do health insurance companies use BMI?

For healthcare providers, checking someone’s body mass index (BMI) is a common first step in obesity screening. The BMI formula involves the relationship between a person’s height and weight. Created to describe populations, it has many well-known drawbacks as a tool to categorize individuals. Yet healthcare providers still commonly use it. The formula classifies someone with a BMI of 30 or above as “obese.”

Insurance companies use a person’s BMI to determine their eligibility for certain types of care. These may include dietary counseling, weight-loss medications, and bariatric surgery. For example, people who want weight-loss surgery are often eligible if their BMI is greater than 40. If they have an obesity-related illness such as diabetes, they qualify with a BMI at or above 35.

Can insurance companies charge higher premiums if you have obesity?

No. Obesity is considered a pre-existing condition under the Affordable Care Act (ACA). So, as with all pre-existing conditions, insurance companies cannot make people with high BMIs pay more in premiums.

Can you be denied health insurance coverage because of weight?

No. Such coverage denials were also outlawed by the ACA.

What kinds of obesity-related coverage do insurance companies have to provide?

Thanks to the ACA, most health plans have to cover obesity screening for adults and children. If the screening warrants, you may also receive weight-loss and dietary counseling. You are entitled to these without having to pay out-of-pocket expenses such as an annual deductible, copay, or coinsurance.

Insurance companies also cover screening for Type 2 diabetes for adults ages 40 to 70 who are identified as overweight or obese. This is important because diabetes is often — though not always — an obesity-related illness.

New state-by-state health insurance mandates for obesity

In addition to the ACA, each state has its own insurance plan and state-specific benefits. State rules about coverage for obesity-related treatments vary from state to state:

Georgia, Utah, and 14 other states offer some coverage for nutritional screening, counseling, or therapy.
Some state plans cover the cost of memberships in weight-management programs. These include New Mexico, Massachusetts, and Michigan.
Seven more states — including Florida, New Jersey, and Tennessee — cover nutritional counseling or therapy for diabetes-related treatments.

Medicare covers obesity-related screening and behavioral counseling if your doctor decides it is medically necessary. But under Medicare guidelines, the nutritional counseling must take place in a primary care setting such as a healthcare provider’s office.

This patchwork quilt of federal and state coverage requirements can be confusing. Ask your insurance provider exactly which types of obesity care they cover and how much they will pay or reimburse.

What obesity care is often not covered by insurance or harder to get coverage for?

Insurance companies often deny coverage or just don’t offer it for weight-loss surgery and medications. Or, they require prior authorization in order to cover a procedure or drug. Again, coverage rules can vary depending on your health plan, employer, and the state you live in.

There are a number of reasons why your insurer might deny coverage for obesity care:

Some plans have an exclusion clause for weight-loss surgery. In such cases, the insurer will probably not cover you, no matter what BMI or obesity-related conditions you may have.
Insurers typically don’t give prior authorization for surgery right away. You may have to first try a medically supervised diet and exercise program, and then present proof.
You may be turned down for coverage if you have refused to have a physical or psychological evaluation.

Bariatric surgery

As of 2019, 23 states had laws requiring commercial health insurers to provide some coverage for bariatric weight-loss surgery. However, insurers often will not cover bariatric surgery unless a person with a high BMI also has a comorbid condition; such conditions include Type 2 diabetes, heart disease, high blood pressure, and many more. Without insurance, the average total cost for bariatric surgery ranges from $20,000 to $24,000, according to a 2019 study.

Both fee-for-service and managed-care Medicaid programs cover bariatric surgery in almost all states. Medicare and Medicare Advantage plans may cover bariatric surgery. You must have a BMI of 35 or above and a comorbid condition such as Type 2 diabetes. You must also show that past medical treatments for obesity have been unsuccessful.

Even if you meet these requirements, Medicare or Medicare Advantage still may not pay for bariatric surgery. Approval is given on a case-by-case basis.

Medication

Private insurance coverage of weight-loss medications varies from plan to plan. In part, this is because Medicare doesn’t cover weight-loss medications at all, and many insurers tend to follow Medicare’s lead.

Still, the FDA has approved several such medications:

Orlistat (Xenical)
Phentermine-topiramate (Qsymia)
Naltrexone-bupropion (Contrave)
Liraglutide (Saxenda)
Semaglutide (Wegovy)

If you’re interested in a specific medication, look over your plan’s formulary (list of covered medications). You may have to contact your insurer to ask about coverage. Sometimes, your doctor has to get prior authorization before prescribing drugs in the formulary. If your plan won’t cover a prescribed item, you have the right to request an exception or appeal the decision.

The bottom line

The Affordable Care Act has improved coverage for people with heavier bodies. Under the ACA, you can’t be denied health insurance based on your weight, nor can you be charged higher premiums. You are entitled to free BMI screening and, in some cases, weight-loss counseling. Coverage for weight-loss medications and surgery is tougher to get. It varies by insurer and the state you live in.

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Written by:

Jeanne Dorin McDowell

Jeanne Dorin McDowell is a journalist and senior editor who has written for major national publications and digital outlets. She is a former correspondent for Time Magazine, and her freelance stories have been published in The New York Times, Scientific American MIND, and Smithsonian, among others.

Edited by:

Caren Weiner, MSIS

Caren Weiner, MSIS, started as a journalist in 1986. She worked for Money magazine and co-wrote its “Guide to the 1986 Tax Reform Act.” From the start, she immersed herself in data on mutual fund total returns and marginal tax rates.

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References

American Society for Metabolic and Bariatric Surgery. (2021). Disease of obesity.

Becker, C. (2019). Health reform and health mandates for obesity. National Conference of State Legislatures.

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