As of 2012, with the passage of the Affordable Care Act (ACA), states can now choose to establish a “benchmark plan” from the selection of existing health insurance plans that will become recognized statewide as a baseline for coverage in that state. Alternatively, a state could choose to use the federal default plan as its benchmark baseline. This was done as part of the process of developing nationwide coverage that is both more uniform and sufficiently broad in what’s covered.
As a result, 33 states chose to give the U.S. Department of Health and Human Services permission to set a federal default for two particular types of obesity diagnosis and treatment coverage as medically necessary. Having officially recognized obesity as a medical disease, most 2015 and 2016 health insurance policies in the country now have certain specific coverage for bariatric surgery and nutritional counseling and therapy.
Bariatric surgery, including the installation of a gastric sleeve, is now required by 23 states as a specific health benefit in all health insurance plans. Prior to passage of the ACA, only five states mandated bariatric treatment coverage of some sort, either specifically or as part of a single morbid obesity coverage option. Three more states require that at least some policies offer this sort of coverage to its residents, though not every policy in the state is required to offer it. All states but Colorado, District of Columbia, Florida, Idaho, Louisiana, Nebraska, Tennessee, Utah, and Washington cover all or some forms of bariatric surgery.
Nutritional counseling and therapy is now a required health benefit in 16 states. These states mandate coverage and reimbursement for dietary screening and obesity-related counseling or therapy. Weight loss programs could also be covered under this mandate. Seven more states cover this sort of treatment only for the purposes of diagnosing or treating diabetes.
Additionally required under the ACA, as of January 1st, 2014, are prohibitions in nearly all 50 states against insuring people for obesity-related diagnosis and treatment. Premium surcharges for obese individuals are prohibited in the health plans in most states, including policies sold via exchanges. Insurers in nearly all 50 states are also prohibited from consumer cost-sharing, including for obesity counseling and screenings for kids and adults. Included in this are prohibitions against annual deductible amounts and enrollee coinsurance or copayments.
Essential Health Benefits (EHB) differ from state to state. The following states use a state-recommended EHB decision regarding gastric sleeve type treatments and nutritional counseling coverage for obesity and/or diabetes: Arizona, California, Colorado, Delaware, District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, Michigan, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Rhode Island, Utah, Vermont and Washington.
The following states use the federal default EHB decision regarding bariatric treatments and nutritional counseling and therapy for obesity and/or diabetes: Florida, Georgia, Idaho, Iowa, Louisiana, Maine, Nebraska, New Jersey, Oklahoma, South Dakota, Tennessee, West Virginia and Wyoming. The data on this subject for Indiana and Virginia were not available.
Certain states further refine their benchmarks by ensuring coverage for particular procedures. For example, coverage in California, Massachusetts, Michigan and New Mexico must include weight loss programs, while previous state laws in Georgia, Indiana and Virginia mandate morbid obesity coverage. For the full list of bariatric and gastric sleeve treatment coverage in each state, visit the National Conference of State Legislatures.