Obesity is linked to chronic diseases like diabetes, high blood pressure, cardiovascular disease and cancer. Because obesity is such a dangerous health risk, Medicaid covers some weight loss programs, services and weight loss medication as outlined below.
Before discussing how Medicaid covers weight loss benefits, it’s important to know how Medicaid coverage is broken down.
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- There is a set of benefits that every state Medicaid program is required to offer. These are called mandatory Medicaid benefits.
- Once that required coverage is met, states then have some flexibility as to other benefits the state Medicare program may cover. These additional benefits are called optional Medicaid benefits.
Some Medicaid coverage for weight loss programs and services may vary from one state to the next when they’re offered as optional benefits.
Does My Medicaid Cover Obesity Screenings?
Obesity screenings are a mandatory benefit for Medicaid beneficiaries under the age of 21. The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit includes obesity screening and is required coverage for all state Medicaid programs.
Some states may also provide this benefit for beneficiaries aged 21 and over, though not every state does.
How Do I Know What My Medicaid Covers?
To find out what optional weight loss benefits your state covers in addition to the national mandatory Medicaid benefits, you can find your state Medicaid program contact information to learn more.
Medicaid Covers Weight Loss Counseling and Education in Some States
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Some state Medicaid programs cover weight loss interventions, education and counseling that promotes healthier eating and physical activity. A state Medicaid program only covers these services as an optional benefit, so they may not be covered in every state.
Does Medicaid Cover Weight Loss Surgery?
Medicaid may cover Weight loss surgery – such as gastric bypass, lap band surgery or gastric sleeve surgery if all of the following requirements are met:
- You are a female over the age of 13 or a male over the age of 15.
- Your Body Mass Index (BMI) is over 35 with at least one comorbidity, such as sleep apnea, high blood pressure, high cholesterol or diabetes. If you’re under the age of 21, your BMI must be over 40 with at least one comorbidity.
- A doctor writes a letter stating that the surgery is medically necessary for you to get to and maintain a healthy weight.
- You pass a psychological exam.
- There is documentation showing that you unsuccessfully tried to manage your comorbidities with standard treatment.
- You complete and document proof of participation in a medically supervised weight loss program for six months, and the program took place within 12 months of the surgery.
- You have a clear understanding that you will have to change your diet and lifestyle after the surgery.
- Nutritional and psychological services must be made available to you before and after the surgery.
Things that may disqualify a beneficiary from Medicaid coverage of weight loss surgery include:
- Long-term steroid use
- Malignant cancer
- Inflammatory bowel disease
- Chronic pancreatitis
- Pregnancy
- Psychological treatment that may interfere with post-operative lifestyle changes
The weight loss surgery must be performed at a Bariatric Center for Excellence, which are facilities having achieved a level of excellence in bariatric surgery.
Each state’s coverage of weight loss surgery may vary.
Is Weight Loss Medication Covered by Medicaid?
Weight loss drugs and weight loss medication are not a mandatory Medicaid benefit, but many state Medicaid programs cover weight loss pills among their benefits.
Medicaid covers a number of prescription drugs, some of which may help you manage your weight as well as other conditions such as heart disease or diabetes.
Does Medicare Cover Weight Loss Programs?
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In addition to Medicaid, Medicare also covers some similar weight loss services.
Screenings and Counseling
Medicare may cover obesity screenings and behavioral therapy for beneficiaries with a BMI of 30 or more. An initial BMI screening and up to two diabetes screenings are covered each year, along with dietary assessments and nutritionist counseling for help with diet and exercise.
Medicare also offers a Diabetes Prevention Program for those who meet certain criteria. The program consists of 16 sessions over the course of six months and includes training, tips and strategies for weight loss and healthy weight management. The initial six months of training are then followed by six more months of less intensive follow-up sessions and 12 additional months of ongoing maintenance sessions.
Medicare also covers medical nutrition therapy (MNT) for beneficiaries with diabetes, kidney disease or who have had a kidney transplant within 36 months. MNT services include a nutrition and lifestyle assessment, nutritional therapy, help managing lifestyle factors and healthy weight loss and follow up visits to monitor diet.
Weight Loss Surgery
Medicare covers weight loss surgery such as bariatric surgery, gastric bypass surgery and lap band surgery for beneficiaries with a BMI of 35 or higher who have at least one comorbidity and have previously undergone treatment for obesity.
Gyms and Wellness Programs
Medicare Advantage (Medicare Part C) plans can cover membership to fitness and health clubs through programs like SilverSneakers or Silver and Fit, which are fitness and wellness programs designed specifically for older adults.
Some state Medicaid programs may also cover gym memberships to help beneficiaries lose weight and stay healthy.
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