Health Reform and Health Mandates for Obesity

1/23/2019

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Most States Have Expanded Health Insurance Coverage for Treatment of Obesity;  Some Target Diabetes

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.  As a result, for most 2015 and 2016 policies --

  • Bariatric Surgery: 23 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.  ** In addition, three states  (GA, IN, and VA) provide that "coverage must be offered..." in at least some policies, but it is not required in all policies. [Description updated 11/1/2015]
  • 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: 

  • No consumer cost- sharing. Most insurance plans in all 50 states are required 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 2013-2016 health plans, including individual state links. ***

NOTE TO CONSUMERS: NCSL provides this information primarily as a tool for state policymakers to understand current state and federal standards.  It is not intended as legal or medical advice related to individual insurance policies or patients.  For information about such specific coverage, authors advise contacting the individual health insurance carriers or the state insurance department, which in most states has oversight authority regarding the applicability of mandates and EHB coverage and reimbursement.

The box allows you to conduct a full text search or type the state name.

State Bariatric
Surgery
Covered? 		Nutritional
counseling
Covered?		 Coverage Description (Includes new Diabetes coverage) EHB Decision  EHB Benchmark
Plan Selected***
Arizona Yes Yes   State recommended AZ largest state employee plan, EPO
California Yes Yes* *Covers weight loss programs State recommended CA largest small group plan, HMO
Colorado - Yes   State recommended largest small group plan, HMO-Point of Service
Delaware Yes -   State recommended DE 2nd largest small group product, EPO
District of 
Columbia		 - Yes* * Covers medical nutrition therapy, obesity preventative services and weight loss drugs District recommended DC Largest small group plan, PPO
Florida - Yes* * Covers diabetes-related nutritional counseling and nutritional guidance Federal Default FL largest small group product, PPO
Georgia Yes** Partial* *Nutritional therapy for people with diabetes
** Morbid obesity coverage must be offered under 1999 state law		 Federal Default GA Largest small group product, Point of Service
Hawaii Yes Yes   State recommended HI Largest small group product, PPO
Idaho   Partial* *Dietary counseling for diabetes Federal Default ID Largest small group product, PPO
Illinois Yes -   State recommended IL largest small group product, PPO
Indiana Yes** - ** Morbid obesity coverage must be offered under a 2000 state law n/a n/a
Iowa Yes -   Federal Default IA largest small group product, PPO
Louisiana - Yes*

*Dietitian visits and diabetes nutrition therapy for diabetic patients; blood pressure,obesity, and cholesterol screening/counseling; and height, weight, and BMI measurements for children.

 Federal Default LA largest small group product, PPO
Maine Yes -   Federal Default ME largest small group product, PPO
Maryland Yes Yes* *Medical nutrition therapy to treat a chronic illness or condition (See features below at note 1) State recommended MD largest small group product, HMO
Massachusetts Yes Yes* * Weight loss programs State recommended MA largest small group product, HMO
Michigan Yes Yes* *Weight loss programs State recommended MI largest HMO plan
Nebraska   Partial* *nutritional counseling for ESRD (End Stage Renal Disease) Federal default NE largest small group product, PPO
Nevada Yes -   State recommended

NV largest small group product, Point of Service
New Hampshire Yes -   State recommended NH 2nd largest small group product,HMO
New Jersey Yes**** Partial*

*For patients with diabetes or verifiable specific disease criteria

****Morbid obesity coverage must be included under state law and as an EHB

 Federal default NJ Largest small group product,HMO
New Mexico Yes Yes* * Includes weight loss programs State recommended NM Largest small group product,PPO
New York Yes -   State recommended NY Largest small group product,EPO
North Carolina Yes Partial* *Nutritional counseling for patients with end stage renal disease (ESRD) State recommended NC largest small group product,PPO
North Dakota Yes Partial* *Medically necessary weight management drugs State recommended ND largest HMO plan
Oklahoma Yes Partial* *Weight loss programs for diabetes self-management Federal default OK largest small group product, PPO
Rhode Island Yes Yes   State recommended Largest small group product, PPO
South Dakota Yes -   Federal Default SD Largest small group product, PPO
Tennessee - Yes* *Dietary guidance from home health workers; dietary counseling, and dietary counseling for patients with Type II diabetes Federal Default TN Largest small group product, PPO
Utah - Yes* *For adults at risk for chronic disease; obesity screening and counseling; nutritional counseling for patients with diabetes and certain other medical conditions. State recommended UT 3rd largest state employee health plan, HMO
Vermont Yes Yes   State recommended VT Largest small group product, HMO
Virginia Yes**   Morbid obesity coverage must be offered within at least one plan by each state-regulated health insurer, under a 2000 state law n/a n/a
Washington   Yes, Partial* *For diabetic patients. State recommended WA Largest small group product,PPO
West Virginia Yes -   Federal Default WV Largest small group product,PPO
Wyoming Yes -   Federal Default WY largest small group product, PPO
           

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 regulations. Data is the most recent available, initially released Feb. 20, 2013, unless dated otherwise.
  • 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, policy associate, NCSL Heath Program, Denver

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