Health Insurance Coverage
There are many people that are prescribed treatment for obesity, but their health insurance neither covers nor reimburses those services.
Denial of insurance coverage for obesity treatment is difficult to understand because:
- Many insurance companies will pay for treating conditions caused by obesity, such as type 2 diabetes and heart disease.
- Most health plans cover numerous conditions, which have neither the mortality nor morbidity of obesity.
Most Americans receive their health care through managed care companies or health maintenance organizations. Unfortunately, few managed care companies include treatments for obesity.
Managed care plans are accredited by the National Committee for Quality Assurance (NCQA). However, NCQA does not examine services for obesity of any health plan. Addressing obesity is essential to the integrity of a national system of accreditation of managed care providers.
Medicare and Medicaid
Medicare is the federal program that provides health services for the elderly and the disabled. In July 2004, the Medicare policy changed to reflect the seriousness of obesity as a medical condition. Previously, Medicare did not consider obesity to be a disease or illness and thus made no payments for any services in connection with it. The new Medicare policy, according to the Department of Health and Human Services (HHS), "would remove barriers to covering anti-obesity interventions if scientific and medical evidence demonstrate their effectiveness in improving Medicare beneficiaries' health outcomes."
The president of the American Obesity Treatment Association stated that the new Medicare policy is a "decision that will open the door not only for better insurance coverage but more medical research and increased education on obesity at the nation’s medical and other health schools."
Weight Management and Health Insurance
Your health insurance company has a special interest in helping you stay healthy…Your good health keeps healthcare costs down for everyone. Being overweight raises your risk of costly health problems such as diabetes. But losing that excess weight lowers the risk to your health…producing potential savings for both you and your insurance company.
It may surprise you then to discover that your health insurance plan will not pay for weight-loss treatments. Most health insurance plans will only pay for the costs of weight-related health problems after they develop. Weight-loss treatments that prevent these problems in the first place or reduce their severity are often not reimbursable. You need to pay for them out of your own pocket.
Inadequate reimbursement for weight-loss treatment is an important issue that you may want to bring to the attention of your health insurance company and/or employer. To help you better communicate your needs and concerns, this insurance web page offers
- Basic information that you should know about obesity-how it’s diagnosed, its complications and costs, and the benefits of treatment.
- Valuable tips on how to request reimbursement for weight-loss treatment from your health insurance company or employer.
- Contact information for the American Obesity Treatment Association (AOTA), which can provide additional support.
Are you Obese?
"Obesity" is a word that means different things to different people. To most people, an obese person is very overweight. But to doctors, a person can be obese even if he or she is not extremely overweight. That's because doctors usually define obesity as an excess of body fat, not just excessive weight.
How can your doctor tell if you're obese? Measuring a person's body fat is not easy. One of the best ways -weighing a person underwater -can only be done in laboratories with special equipment. On the other hand, doctors can measure the thickness of a person's skin folds right in their own offices. This measurement of body fat, however, is not always accurate.
Doctors often rely on weight-for-height tables. These tables provide a range of acceptable weights for a person of a given height. Weights that are outside the range carry a higher risk of death. While these tables are a good "rule of thumb" measurement, they pose a number of problems. They are outdated, for example, and do not provide information on the risk of health problems other than death.
Increasingly, doctors are using a more "state-of-the-art" method called the body mass index (BMI) to check for obesity. BMI is calculated using a mathematical formula that includes a person's weight and height measured in metric units (kilograms and meters). In recent studies, BMI was used to estimate the risk of death and other health problems in people who were obese. As a result, BMI is now recommended by many obesity experts and key government agencies. You may check your BMI by clicking here. The math and metric conversions will be done for you, as well as calculate your BMI.
If your BMI is 25 kg/m squared or over, you are likely to be at greater risk due to your weight.
The High Price of Obesity
If you're obese, you're not alone: so are a record number of other Americans. Roughly 60 million adults are obese.
When it comes to being overweight, though, there's no safety in numbers. Your weight can make you the target of discrimination in your personal and professional life. (1) And it can seriously jeopardize your health. Obesity can cause:
- heart disease (2)
- diabetes (3)
- high blood pressure (4)
- high cholesterol (4)
- certain types of cancer (5)
- gallbladder disease (6)
- gout (7)
- certain types of arthritis (8)
- respiratory disease (9)
- premature death (10)
The direct health care costs of obesity amount to approximately $100 billion. Another $33 billion a year is spent on weight-loss products and programs, most of which comes right out of consumers' pockets. (11)
Losing Weight for Your Health's Sake
You can probably think of many reasons to lose weight, but none is more important than improving your health. By losing weight, you can reduce the risk of nearly all of obesity's complications. You can also begin to bring down the cost of managing the complications of your extra weight.
How much weight do you need to lose to reduce these risks? Good news...even a modest amount (just 5% to 10% of your initial weight) can really reduce your risk of serious health problems. (12)
A Strong Support Network
To successfully manage your weight, you may rely on a number of different resources. In addition to your own effort and commitment, you may need the support of family, friends, and healthcare professionals. Frequently, you also need money...money to purchase weight-loss products or services, such as:
- diet foods or meal replacement products
- at-home exercise equipment or membership at a health club
- membership in a weight-loss program
- behavioral or nutritional counseling
- prescription drug therapy
- gastric reduction surgery
These treatment approaches can be effective in controlling weight. For this reason, your doctor may recommend that you try one or more of them.
Your health insurance company, however, may be reluctant to pay for the costs of your weight-loss treatment, even if it is recommended by your doctor. The company may be unwilling to reimburse you for obesity treatment costs for many reasons. For example, the company's decision makers may not fully appreciate that obesity is a chronic medical condition, like high blood pressure or high cholesterol. Or they may not be convinced that a person will keep weight off long enough to reduce complications and costs. It's also possible that the company is not aware of your need for reimbursement of obesity treatment costs.
Do's and Don'ts of Communicating with Your Insurance Company
If you would like to urge your health insurance company to help you pay for weight-loss treatment, it's up to you to make your needs known. It's up to you to ask for the company's help in improving your chances of becoming a healthier person.
How do you ask for the support that you need? Here are some important tips on how to start the wheels turning:
- Do have confidence in the fairness of your request. Obesity is a chronic medical problem with serious complications. Even modest weight loss is likely to reduce your risk of complications, improve your health, and reduce healthcare costs. You're well within your rights as a valued customer to make this case to your insurance company.
- Do go through the proper channels within your insurance company. Many health insurance companies offer you an "800" customer service number that you can call with requests or complaints. In most cases, the first person you contact at the insurance company is the customer service representative. This person should be familiar with your specific health plan.
If you would like to take your case beyond your insurer's customer service representative, you may wish to speak to one or more of the following individuals:
- the Manager of Customer Service
- the Director of Customer Service
- the Marketing Director for new Products or Program Development
Your employer's health benefits manager may be able to put you in contact with these individuals.
- Don't hesitate to get your employer's health benefits department involved on your behalf.
Discuss your needs with your health benefits manager at work. Request his or her support in gaining reimbursement for your treatment. Your health benefits manager may be very experienced in negotiating with insurance companies, so you should carefully consider his or her recommendations. Many employers will support your efforts to be reimbursed for the treatment you need to stay healthy and productive.
- Don't be confrontational, argumentative or hostile when making your request or discussing your concerns. Do be assertive and persistent.
Maintain a "cool head", while clearly and firmly expressing your needs. Although you and your insurance company are both interested in keeping you as healthy as possible, you may encounter some resistance. Stick to your guns, even if company representatives are uncooperative or impolite.
- Do keep accurate and well-organized records of all communications with your insurance company. Take careful notes when talking with company employees by telephone. Record dates, times, and names and keep copies of all written correspondence.
- Do send the insurance company a written letter repeating your concerns and requests after any phone conversation with one of its representatives. Keep your communications simple and to the point. Also, include all of the necessary information, such as your name, policy number and other identification information. It's also a good idea to enclose copies of receipts for unreimbursed treatments, medical test results, and statements from your doctor.
- Do ask your doctor to contact your health insurance company. Your doctor should be sure to mention any medical problems associated with your obesity as well as details of your treatment. The support of your doctor can make a big difference.
- Do some homework on the policies of other insurance companies. Some insurance plans have begun to offer special discounts for weight-loss programs. Others reimburse their members for the cost of the programs if they work. Don't be afraid to mention the favorable policies of competitors to your own insurance company.
- Don't forget to follow up if you don't get the response you want the first time. An insurance company representative may not be able to provide you with the information that you need right away. If so, ask that representative to follow up within a reasonable period.
Coping with Rejection
Despite your best efforts, your insurance company may still turn down your request. Don't be discouraged. Rejected requests are common, but often are not the final word. There are still several steps that you can take, including:
- Repeat your request.Ask your insurance company representative to reconsider your request. In some companies, after your third request, your case is automatically passed on to a higher authority. Being persistent will show the company how important this issue is to you.
- Appeal the decision to another level within the company.Each health insurance plan may have several levels of appeal. This can be a time consuming process. Keep in mind, though, that your first contacts within the insurance company are not likely to be the company's real decision makers. The appeals process may lead you to the very people responsible for setting policy about reimbursement for weight-loss treatments. Each health insurance plan may have several levels of appeal. This can be a time consuming process. Keep in mind, though, that your first contacts within the insurance company are not likely to be the company's real decision makers. The appeals process may lead you to the very people responsible for setting policy about reimbursement for weight-loss treatments.
The individuals responsible for appeals are different in every insurance company. But you may want to direct your appeal to one or more of the following individuals:
- A Medical Appeals Officer
- A Case Management Nurse
- the Medical Director
- Keep your employer's health benefits manager informed. Share copies or summaries of your communications, including rejection notices. This will help the benefits manager stay familiar with your situation if he or she chooses to discuss it with the health insurance company.
- Contact your state's insurance commission in writing to describe your needs and difficulties. Send copies or summaries of your communications with the insurance company. Then, be sure to let your insurance company know that you've contacted the commission on your own behalf.
- Write to state and federally elected officials who may be able to assist you in the appeals process. Update them on your situation and enlist their support on this important issue.
What Can I Do?
From the information we have provided, you can use what is helpful to explain the importance of coverage and reimbursement for obesity treatment to your employer, managed health care plan or insurance company. Help change the picture on reimbursement. If not for you, do it for the millions of adults and children who need help paying for treatments.
Be an advocate. Changes in employer paid health insurance or public programs like Medicare and Medicaid will not come overnight. And the changes will not happen until people like you start demanding it. AOTA has tried on this site to connect you with the information you may need to help make the case for change. If your plan changes coverage or you have an interesting experience to report, let us know so that we tell others.