No More General Exclusions for Obesity?
Here’s a rare bolt of clarity from a government agency. The U.S. Department of Labor has just published a set of FAQs that includes a question about general exclusions for obesity in health plans under the Affordable Care Act (ACA). Are they permissible? The answer:
No. Consistent with PHS Act section 2713, its implementing regulations, and current USPSTF recommendations, non-grandfathered plans and issuers must cover, without cost sharing, screening for obesity in adults. In addition to such screening, the USPSTF currently recommends, for adult patients with a body mass index (BMI) of 30 kg/m2 or higher, intensive, multicomponent behavioral interventions for weight management. The recommendation specifies that intensive, multicomponent behavioral interventions include, for example, the following:
• Group and individual sessions of high intensity (12 to 26 sessions in a year),
• Behavioral management activities, such as weight-loss goals,
• Improving diet or nutrition and increasing physical activity,
• Addressing barriers to change,
• Self-monitoring, and
• Strategizing how to maintain lifestyle changes.
Since forever, general exclusions for obesity treatment have been part of the standard language you would find in the benefit summaries for many, if not most, health plans. So when the ACA went into effect, many health plans kept those exclusions. The answers people got about coverage for intensive behavioral therapy varied widely, despite the ACA’s requirement to cover preventive services like IBT.
We don’t think that this is the end of struggles to get good access to evidence-based obesity care. But, hey, it’s a start.
“The greatest beauty always lies in the greatest clarity.” — Gotthold Ephraim Lessing
Click here for the FAQs. See #6 for the question about weight management and obesity.
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October 28, 2015