Most States Have Expanded Health Insurance Coverage for Treatment of Obesity; Some Target Diabetes
A web supplement to an NCSL LegisBrief, OBESITY: PROGESS AND CHALLENGES, published May 2014 [may require a password]
Beginning in 2012, the federal Affordable Care Act (ACA) allowed states to select an existing insurance plan to be the statewide “benchmark plan," a step toward more uniform and in-depth coverage nationwide such plans have to cover specified. This process led to 33 states selecting—or allowing the U.S. Department of Health and Human Services to establish as a federal default—two types of coverage for diagnoses and treatment of obesity as a medically recognized disease.
- Bariatric Surgery: 22 states now have a specific health benefit requirement to cover bariatric or gastric bypass surgery, which reduces the physical size of a patient's stomach and the urge to over-eat. Before the ACA, five states had a state mandate to cover, or offer morbid obesity coverage as one option. See explanatory notes in the table below.
- Nutritional Counseling and Therapy: 16 states now include some coverage and reimbursement for dietary or nutritional screening, counseling and/or therapy for obesity, sometimes including weight loss programs. An additional seven states cover nutritional counseling or therapy, but only for a diabetes-related diagnosis or treatment. In combination, some or all such coverage is required in 23 states.
In addition, as of Jan.1, 2014, the ACA requires:
- Most insurance plans in all 50 states to cover certain services with no cost-sharing, including obesity screening and counseling for all adults and children. This includes no annual deductible amount, no enrollee copayments or coinsurance.
- Premium surcharges for being obese are prohibited in most insurance policies in all 50 states, including those sold through exchanges.
The table below lists state-specific Essential Health Benefits (EHB) and what specific obesity-related services and treatments are covered by each benchmark plan for 2013-2015, including individual state links. ***
The box allows you to conduct a full text search or use the dropdown menu option to select a state.
Acronyms and Notes
- *** The state EHB details have been posted online by CMS/HHS, based on material selected and submitted by, or obtained from, states, in combination with ACA requirements in statute and federal regulatons. Data is the most recent available initially released Feb. 20, 2013, unless dated more recently.
- EPO: Exclusive Provider Organization
- HMO: Health Maintenance Organization
- PPO: Preferred Provider Organization
- 1 - Maryland also includes: Professional nutrition therapy for patients at nutritional risk, obesity evaluation and management at well child care visits, office visits for the treatment of childhood obesity, and nutritional services to treat a number of conditions, including diabetes. Maryland also has had a state law coverage mandate since 2001.
About the Authors: Richard Cauchi, program director. Additional research by Ashley Noble, research analyst II, NCSL Heath Program, Denver