Medicare's coverage for obesity treatment: A clarification
Revamped Guide on Obesity Treatment and Medicare Coverage
Hey there, let's talk about obesity and what Medicare has to say. First off, it's important to know that obesity, defined as a body mass index (BMI) of 30 or more, affects nearly one-third of Americans, including a significant number of Medicare beneficiaries.
As a chronic health condition, Medicare only expends coverage on certain obesity-related treatments. Unfortunately, Medicare doesn't foot the bill for general weight loss programs or obesity medications. But don't fret! There's still help to manage obesity within Medicare limits.
Intensive Behavioral Therapy
Under Original Medicare's Part B, if your BMI soars beyond 30 and your doc is convinced it's a problem, you may qualify for intensive behavioral therapy for your weight woes. This therapy usually begins with a preliminary evaluation, followed by guidance and advice on diet and exercise.
While Original Medicare takes care of most of the therapy cost, it doesn't cover a registered dietitian or nutritionist. However, if you've got diabetes or kidney disease, those appointments are covered for 36 months post-diagnosis or transplant.
Weight Loss Surgery (Bariatric Surgery)
If lifestyle adjustments don't cut it, you might be a candidate for weight loss surgery under Part A, which covers inpatient surgeries and treatments. Here, your BMI needs to be a hefty 35, and your medical history should indicate that previous nonsurgical approaches have failed. Among the surgeries, Medicare covers are gastric bypass and laparoscopic gastric banding.
Surgeries cosmetic in nature, like tummy tucks or liposuction for fat reduction, are not covered.
Weight Loss Drugs (GLP-1 Agonists)
Medicare typically doesn't cover weight loss drugs like GLP-1 agonists specifically for obesity treatment. However, there's a potential change coming down the line in 2024, with CMS considering expanding Medicare Part D coverage of these drugs for obesity treatment. This change could assist approximately 3.4 million Medicare beneficiaries, but it's likely to cost the agency $24.8 billion over a decade. The final decision on rolling out this change is still up in the air.
Medicare Advantage Plans
If you opt for a private Medicare Advantage (Part C) plan, you can expect the same coverage as Original Medicare. Although, some plans may offer goodies like gym memberships, nutritious meal delivery services, and coverage for fitness programs. These programs help in maintaining a healthy weight, such as SilverSneakers, Renew Active, or Silver&Fit.
Costs
Upon meeting the annual Part B deductible of $257, Part B will cover 80% of eligible treatments or services, while Part A may cover hospital stays, surgeries, and other services after an initial deductible of $1,676. However, after 60 days of inpatient care, there's an additional cost for hospital stays.
Monthly premiums for Part C plans averaged around $17 in 2025, and the national Part D base beneficiary premium stood at $36.78.
Glossary
- Out-of-pocket cost: The amount a person pays for healthcare when Medicare doesn't cover the full cost or doesn't provide coverage. This includes deductibles, coinsurance, copayments, and premiums.
- Premium: The monthly amount someone pays for Medicare coverage.
- Deductible: The yearly amount a person must pay out-of-pocket before Medicare begins covering treatments.
- Coinsurance: The percentage of treatment costs a person must cover out-of-pocket. For Medicare Part B, the coinsurance fee is 20%.
- Copayment: A fixed dollar amount a person must pay for certain treatments when using insurance.
Takeaway
While Medicare only covers certain obesity-related treatments, like counseling and weight loss surgeries, it doesn't pay for standard weight loss programs or obesity medications. However, it's worth noting that proposals to include anti-obesity medications under Medicare Part D are currently being debated. The final decision depends largely on the economic impact and ongoing policy discussions.
- Intensive behavioral therapy for weight management is covered partially under Medicare Part B, if your BMI surpasses 30 and your doctor deems it necessary.
- Weight loss surgeries like gastric bypass and laparoscopic gastric banding are covered under Medicare Part A, but cosmetic procedures such as tummy tucks or liposuction for fat reduction are not.
- Medicare typically does not cover weight loss drugs like GLP-1 agonists specifically for obesity treatment, but there is a potential change coming in 2024, which could affect around 3.4 million Medicare beneficiaries.
- Under Medicare Advantage (Part C) plans, you may receive additional benefits like gym memberships, nutritious meal delivery services, and coverage for fitness programs that aid in maintaining a healthy weight.
