Cancer survivors face unique challenges in obtaining access to weight management and obesity treatment services. Currently coverage for obesity treatment is variable and, for patients with cancer, a diagnosis of cancer does not ensure coverage. Specific information regarding coverage for obesity services is provided below.
Intensive Behavioral Counseling
In 2012, CMS added intensive behavioral counseling for adult obesity, a grade B recommendation of the U.S. Preventative Services Task Force (USPSTF), as a covered service only when provided by a primary care physician or practitioner in a primary care setting. CMS defines a primary care setting as one where services are provided by clinicians “who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” CMS defines a primary care practitioner as one who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, obstetrics/gynecology, or pediatric medicine OR who is a nurse practitioner, clinical nurse specialist, or physician assistant.
Medical Nutrition Therapy
CMS also provides coverage for Medical Nutrition Therapy (MNT) only to individuals with kidney disease or diabetes. MNT is defined as a specifically tailored dietary plan developed and monitored by a registered dietician or nutrition provider. The provider must meet certain requirements as defined by CMS. This service is covered when delivered by a registered dietician or nutrition professional according to nutrition practice guidelines.
To qualify for coverage, individuals must meet the following criteria:
- Have a BMI of 35 or greater
- Have at least one weight-related problem (diabetes, heart disease, or sleep apnea)
- Have documented evidence of repeated failure to lose weight in medically supervised weight loss programs (diet, exercise programs/counseling, or drug therapy)
Additionally, bariatric surgery will only be covered if:
- Individuals undergo psychological evaluation
- All other medical treatments have been ruled out
- The surgery is performed at a Medicare-approved "Center of Excellence"
- The specific procedure used is approved by Medicare
Medicare does not cover the services of an exercise therapist or trainer, or physical exercise classes. And, as yet, Medicare Part D does not cover drugs for the treatment of obesity.
Medicaid & State Insurance Coverage of Obesity-Related Services
Very few states ensure coverage of recommended treatments for adult and pediatric obesity through Medicaid or private insurance (Lee et al, 2010).
- Only eight state Medicaid programs appear to cover all recommended obesity treatment modalities for adults.
- Eligible children under Medicaid have coverage for comprehensive obesity services through the Early and Periodic Screening, Diagnostic, and Treatment program; however, it is not clear whether states are actually covering necessary services.
Learn more about your state’s Medicaid plan and to find your state’s Medicaid agency information here.
Obesity-Related Provisions in the Affordable Care Act (ACA)
As part of the preventive services benefit, the ACA requires CMS and most private insurance to provide coverage for screening for obesity. ACA also requires that all counseling services are evidence-based and have a rating of “A” or “B” in the current U.S. Preventive Services Task Force USPSTF recommendations, without co-pay to members. An “A” or “B” letter grade indicates the Task Force finds there is high certainty that the services have a substantial or moderate net benefit. However, counseling services are only covered when provided by primary care practitioners..
Obesity Treatment as an Essential Health Benefit
The Affordable Care Act establishes ten categories of "essential health benefits," one of which is “preventive and wellness services and chronic disease management.” However, the proposed regulation does not define this category, in general, nor address obesity specifically. The effects of the ACA on access to obesity treatment services are unclear at this time.