Weight loss programs in the U.S: What insurance does & does not cover

If you’ve had difficulty losing weight with diet and exercise alone, it may be time to consider medical weight loss. Medical weight loss is leveraging the expertise, guidance and support of a physician, or team of healthcare providers, for weight loss efforts. This often includes behavioral interventions and counseling, which could be provided by a Registered Dietitian or medical provider such as a Physician, Physician Assistant, or Nurse Practitioner. It may also include the use of FDA-approved weight loss medication, bariatric surgery, or medical weight loss devices as appropriate. You may be wondering, “What’s this going to cost me? Are medical weight loss programs covered by insurance?” Well, the short answer is that it varies. It will depend on the treatment provided, the way the offering is set up, and your insurance. Keep reading to learn more about options. 

Insurance coverage for obesity treatment

In 2013, the American Medical Association, with the support of many other healthcare organizations, designated obesity as a chronic disease requiring prevention and treatment. This decision was based on mounting evidence that obesity is a complex condition influenced by biology, environment, and behavior, and that it can lead to other serious health conditions such as type 2 diabetes, heart disease, stroke and many cancers. 

As a result of this designation and the high prevalence of obesity, there have been significant advances in treatment options for helping people to lose weight and keep it off. We have research-backed behavioral interventions and medications shown to produce significant weight loss. We have new, effective devices and safer surgical procedures as well. Despite all of these advancements, affordability of care remains a barrier to many patients seeking treatment.

What kind of weight loss treatments are covered by insurance?

Insurance coverage of obesity treatment will vary depending on your state and insurance plan. Treatment options that may be eligible for reimbursement include:

• Behavioral Intervention and Counseling 
• Weight Loss Medication(s)
• Bariatric Surgery
• Medical Weight Loss Devices
  

Behavioral intervention and counseling

Changing behaviors around diet and physical activity are an important component of any weight loss program. As are ongoing support and accountability. The extent and frequency of counseling sessions can vary significantly depending on the type of provider or provider(s) you see for weight management. Such treatment may be guided by a physician or other medical provider, but could also be provided by a Registered Dietitian or psychologist. Some weight loss programs provide a multidisciplinary approach using a combination of medical providers, dietitians, and/or psychologists. 

Despite this treatment being foundational to weight management and the proven benefits, health insurance coverage varies. Under the Affordable Care Act, insurance providers are required to cover “obesity screening and counseling”. But there is no further guidance as to how often you can see your medical provider for counseling or if you can see another provider such as a Registered Dietitian or psychologist. Coverage of these services is going to vary from state-to-state and depend on your particular insurance plan. The best way to know what is covered is to check your plan documents or contact your insurance carrier to get more information.

Weight loss medication

When comprehensive behavioral intervention and counseling aren’t enough, FDA-approved weight loss medication may be recommended. These medications are not appropriate for all patients though. Prescription weight loss medication is indicated for persons with a body mass index (BMI) ≥ 27 kg/m² with a weight-related medical problem or a BMI ≥ 30 kg/m² who have not responded to more conservative treatment. Additionally, medications are not safe for all persons, so a thorough review of your health history and the current medications you’re taking is important in determining if weight loss medication is right for you. 

When it comes to coverage, there is no clear answer to the question “Is weight loss medication covered by insurance?”. It really varies depending on the medication being prescribed and your insurance benefits. Working with a provider who specializes in obesity medicine can help you to work through some of the nuances of insurance coverage as they are familiar with completing prior authorization requests and can discuss alternative options if the medication prescribed is not covered by your plan. At Form Health, the clinical team is familiar with these challenges and can help you to navigate the process; although coverage is not a guarantee. All Form patients are paired with a board-certified physician that specializes in obesity medicine, so they will work with you to try to find a medication that is both beneficial and affordable.

Bariatric surgery

Bariatric surgery is the most effective treatment for severe obesity, helping patients lose 20-30% of their initial body weight. Surgery is indicated for persons with a BMI ≥ 35 kg/m² with a weight-related medical problem or a BMI ≥ 40 kg/m². 

Surgical procedures include gastric banding, Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and duodenal switch. The decision to pursue bariatric surgery and the most appropriate procedure should be discussed at length with a healthcare provider who specializes in obesity medicine and/or bariatric surgery. Additionally, a long-term commitment to a healthful diet and regular physical activity are necessary for success and safety following bariatric surgery, so finding a team to assist with establishing and maintaining those habits is an important part of the process. Sometimes, certain weight loss medications can be used alongside gastric bypass surgery.

Coverage of bariatric surgery has improved in the last decade as 23 states have a specific health benefit requirement for the coverage of bariatric surgery. Additionally, Medicare and most Medicaid plans cover this treatment option. If you have private health insurance, coverage will depend on your state laws and benefit plan, so it is best to contact your insurance carrier for more information.

Medical weight loss devices

Medical devices used to assist weight loss are relatively new to the treatment toolbox. Just like with medications and bariatric surgery, they are meant to be used in a combination with a reduced-calorie diet, increased physical activity, and behavior changes that promote weight loss and are for patients who have not responded to more conservative treatment approaches. Some FDA-approved devices for obesity treatment include the following: 

• Laparoscopic gastric band - an adjustable band placed around the stomach that can be inflated to make the stomach smaller with the intention of decreasing food intake. Gastric band is indicated for patients with a BMI ≥ 35 kg/m² who have a weight-related medical problem or a BMI ≥ 40 kg/m². Insurance that covers bariatric surgery will generally cover the cost of a gastric band.

• Intragastric balloon - a gas- or liquid-filled balloon swallowed or placed inside the stomach and meant to occupy space to promote a sensation of fullness. Unlike a gastric band, balloons are placed by an endoscope, and removed after 6 months. They are indicated for patients with a BMI of 30-40 kg/m². Unfortunately the intragastric balloon is not usually covered by health insurance and the out-of-pocket cost is going to vary depending on the provider performing the procedure, but can range from $5,000 to $12,000 or more.
  
• Plenity^Ⓡ - capsules filled with hydrogel particles and swallowed prior to meals in order to absorb water and occupy space in the stomach, leading to reduced food intake. Plenity is indicated for patients with a BMI of 25-40 kg/m². Plenity can be purchased through the manufacturer’s website for $98 per month for qualifying patients.
  

Insurance coverage with the Form Health medical weight loss program

Form Health’s insurance-covered medical weight loss program will provide patients with a personalized weight loss path that can assist them with losing weight and improving their overall health. 

If you’re interested in seeking medical care for weight management and working with experts to develop a personalized weight loss plan, give Form Health a try! Our insurance-covered medical weight loss program uses tools like behavioral health, nutrition, physical activity, and FDA-approved medication, if appropriate, as parts of a comprehensive weight loss program to help you lose weight and improve your health. 

If you’d like to get back on track, take our quiz to see if the Form program is right for you!

Plenity^Ⓡ is a registered trademark of Gelesis, Inc.