Will Medicare Cover My Obesity? 

Obesity is a major problem in modern-day America. During the span of 2017 to 2018, the U.S. obesity prevalence was 42.4%. This represents a rapid increase from 30.5% in the span from 1999 to 2000. The estimated annual medical cost of obesity in the U.S. ranges from $147 billion to nearly $210 billion.¹

All these numbers translate to a major public health problem. Obesity is a risk factor for many other conditions, including heart disease, high blood pressure, diabetes and arthritis. If you are trying to figure out how to manage your obesity through Medicare benefits, you’re not alone.  Let’s break down how the various parts of Medicare can help you reach your weight-related goals.

Original Medicare and Obesity: What’s Covered by Part A & B

Part A
Part A (hospital care) covers inpatient hospital services and skilled nursing facilities. If you have a body mass index (BMI) of 35 or higher, you’re considered severely obese and Medicare will cover bariatric surgery if your doctor deems it medically necessary. In addition to the BMI requirement, you must:

• Have at least one obesity-related condition, also known as a comorbidity 
• Have a history of unsuccessfully trying to lose weight through more traditional methods such as diet and exercise  

Medicare Part A covers the following types of bariatric surgery:

• Sleeve gastrectomy 
• Roux-en-Y gastric bypass 
• Vertical gastric banding 
• Adjustable gastric banding 
• Biliopancreatic diversion with duodenal switch

Medicare coverage excludes other procedures including open sleeve gastrectomy and the gastric balloon.
Keep in mind that you’ll be responsible for your deductible ($1,556 in 2022) as well as provider visits.

Part B
Part B (medical care) covers both medically necessary and preventative services relating to your obesity.
If you have a BMI of 30 or more, you qualify for obesity screenings as well as behavioral and nutritional counseling that will be completely covered so long as your doctor or provider is Medicare-approved.

However, there are other weight-loss treatments that are NOT currently covered by Medicare. These include:

• Weight-loss programs 
• Cosmetic procedures  
• Weight loss meal delivery services

Moreover, both Part B and Medicare Advantage cover a diabetes prevention program for one-time participants with a BMI of 25 or over who have never been diagnosed with Type 1 or Type 2 diabetes or end-stage renal disease.
To participate, your plasma glucose test results and hemoglobin must fall within a specified range.

Living with more than one chronic condition?
You may qualify for Chronic Care Management under Part B if you suffer from multiple chronic conditions caused by obesity such as arthritis, diabetes, heart disease or high blood pressure.  

Part B Chronic Care Management services include:

• Around-the-clock provider access 
• At least 20 minutes of related services monthly 
• An individually crafted care plan 
• Regular check-ins with your doctor or provider

Providers who can bill for this include:

• Physician assistants 
• Nurse specialists 
• Midwives 
• Nurse practitioners

Those who can NOT bill for Chronic Care Management include:

• Dentists 
• Podiatrists 
• Psychologists 
• Limited-license doctors 

Medicare Advantage and Obesity Care

Medicare Advantage, also known as Part C, offers all the services provided by Original Medicare, but typically provides more extensive coverage and benefits. If you wish to use your Medicare Advantage to allay your obesity, you may be able to take advantage of:

• Fitness programs like SilverSneakers or discounts on gym membership 
• Weight management services like Nutrisystem or Weight Watchers 
• Other wellness programs 

A few tips on choosing a wellness program: 

1. Talk openly to a trusted doctor or provider about your health concerns.  

2. Find a fitness routine that works with your lifestyle and thus can be maintained long-term.  

3. Make sure that your program has a holistic focus that looks at habits, not just diet.  

Obesity is widely understood to increase your chances of certain chronic conditions like heart disease, diabetes and arthritis. If you live with a chronic condition, you might consider a Chronic Condition Special Needs Plan (C-SNP).

These plans offer benefits and services not found in other types of Medicare Advantage Plans. One of the most notable benefits of a C-SNP is the use of care coordinators. These care coordinators help you stay on track with your care. For example, a care coordinator can help schedule appointments, get the right prescription drugs and monitor other health-related activities.

If you opt for a Chronic Conditions Special Needs Plan, you will likely have to choose a primary care doctor and get specialist referrals, in addition to making sure that you are aware of out-of-network costs.

Coverage for Anti-Obesity Drugs through Part D

Medicare Part D (prescription care) is an add-on to Original Medicare, which does not provide prescription coverage. This is a controversial and evolving area when it comes to obesity, as anti-obesity medications are not covered by Medicare given a provision excluding drugs labeled as weight-loss or weight-gain agents.

There is Congressional action afoot to change this. The Treat and Reduce Obesity Act seeks to add obesity drugs onto Part D.² This law would also expand benefits for intensive behavioral counseling and cover providers such as dieticians, psychologists and specialty physicians.

Medicare Supplement Insurance and Obesity Care

Like Medicare Advantage, Medicare Supplement Insurance Plans may help cover the cost of weight-loss programs such as Weight Watchers or Nutrisystem. However, it isn’t a standard benefit and availability varies greatly between insurance carriers.

Can I be denied a Medigap plan for being overweight?
Also known as Medigap, these plans come with underwriting if purchased outside of open enrollment. This can be challenging for those living with obesity. If you’re simply overweight with no other conditions, you are likely to be accepted. That said, if you have any comorbidities, it’s possible you may be declined. 

When you apply for Medigap, you will be asked to provide your height and weight. At that point, it is the carrier’s decision as to whether they will approve you – and standards vary. If you’re approved, you may still find that your premium is higher than normal depending on how overweight you are or what other conditions you have. 

Carriers typically break down applicants into three weight ranges

• The lowest weight range has the most competitive rates 
• The middle weight range carries an added 10% to the monthly premium 
• The highest weight range carries an added 20% to the monthly premium
  

If you’re concerned that your weight is an issue, you’re not necessarily out of luck. If you sign up during your Medigap Open Enrollment Period, you won’t have to worry about medical underwriting. If you have questions about your individual situation, contact a licensed Ensurem agent at the phone number on this page.

What are the Risk Factors for Obesity?

According to the National Heart, Lung, and Blood Institute, the following are some major risk factors:

• Family history and genetics 
• Unhealthy environments 
• Unhealthy lifestyle habits

While treatments for obesity continue to emerge, Medicare can connect you with resources to help shed the pounds in a healthy, measured way.

Conclusion

There are many things that can lead to being overweight and losing weight can feel unattainable at times.
Your health care plan can be a powerful tool to help you reach your goals, but it’s important to find the right coverage for your lifestyle.

You don’t have to do it alone! Reach out to an Ensurem licensed agent to learn how Medicare can help you battle the bulge – and win. We’re here for you.

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