Coverage of Obesity Treatment: A State-by-State Analysis of Medicaid and State Insurance Laws

Transcription

1 Reserch Articles Coverge of Obesity Tretment: A Stte-by-Stte Anlysis of Medicid nd Stte Insurnce Lws Jennifer S. Lee, MD,b Jennifer L.O. Sheer, MPH b Nncy Lopez, JD, MPH b Sr Rosenbum, JD b SYNOPSIS Objectives. We determined whether stte Medicid progrms cover recommended tretments for dult nd peditric obesity nd to wht extent sttes regulte the tretment nd coverge of obesity by privte insurers. Methods. We conducted stte-by-stte document review of Medicid mnuls nd privte insurnce lws nd regultions. Results. Eight stte Medicid progrms pper to cover ll recommended obesity tretment modlities for dults. Only 10 sttes pper to reimburse for obesity-relted tretment in children. In the smll-group insurnce mrket, 35 sttes expressly llow obesity to be used for rte djustments, while 10 sttes do so in the individul mrket. Two sttes expressly llow obesity to be used in eligibility decisions in the individul mrket. Five sttes provide for coverge of one or more tretments for obesity in both smll-group nd individul mrkets. Conclusions. Very few sttes ensure coverge of recommended tretments for dult nd peditric obesity through Medicid or privte insurnce. Most sttes llow obesity to be used to djust rtes in the smll-group nd individul mrkets nd to deny coverge in the individul mrket. Deprtment of Emergency Medicine, The George Wshington University, Wshington, DC b Deprtment of Helth Policy, The George Wshington University, Wshington, DC Address correspondence to: Jennifer S. Lee, MD, Deprtment of Emergency Medicine, The George Wshington University, 2150 Pennsylvni Ave., Ste. 2B-417, Wshington, DC 20037; tel ; fx ; e-mil <jelee@gwu.edu> Assocition of Schools of Public Helth 596

2 Stte Obesity Tretment Coverge 597 Obesity is one of the most chllenging public helth problems we fce s ntion. More thn 32% of Americn dults re obese nd more thn 17% of children nd dolescents re overweight. 1 Obese individuls re more likely thn norml-weight individuls to develop hypertension, hert disese, dibetes, nd stroke, mong other diseses. 2 8 The incresing prevlence of obesity nd its significnt helth consequences re strining our helth-cre system. In 2000, the totl cost of obesity in the United Sttes ws n estimted $117 billion $61 billion in direct costs nd $56 billion in indirect costs. 9,10 Through Medicre nd Medicid, federl nd stte governments finnce pproximtely hlf of direct medicl expenditures ttributble to overweight nd obesity in the U.S. 11 Medicid enrollees hve the highest prevlence of obesity compred with those who re uninsured, privtely insured, or in Medicre. As result, 11% of U.S. dult Medicid expenditures re spent on treting obesity-relted medicl conditions. 12 In response to incresing obesity rtes nd the concomitnt economic nd helth chllenges these rtes impose, sttes hve responded in vriety of wys. Some hve encted tx lws tht crete incentives for helthy behviors or penlize unhelthy hbits. 13 Some sttes hve trgeted competitive foods in schools nd creted new physicl eduction nd fitness requirements. Locl nd stte governments hve utilized plnning, zoning, nd trnsporttion policies to promote helthier lifestyles. But few studies hve exmined stte policy with regrd to public or privte insurnce coverge of helth-cre services for obesity itself. Currently, there re no known sttutes or regultions to preclude sttes from covering tretment for obesity through Medicid or privte insurnce. In fct, in 2004, the Centers for Medicre nd Medicid Services (CMS) removed lnguge from the Medicre Coverge Issues Mnul stting obesity ws not n illness. 14 And reserch hs demonstrted tht under Medicid, eligible children lredy hve coverge for comprehensive obesity services through the Erly nd Periodic Screening, Dignostic, nd Tretment (EPSDT) progrm. 15 EPSDT progrm benefits include complete periodic nd s-needed ssessments of children s helth nd development from birth to ge 21. The exmintions include regulr ssessments of nutritionl sttus, such s height nd weight mesurements, nd questions bout dietry prctices. 16 For children identified with helth condition, sttes must rrnge for ll mediclly necessry tretments flling within federlly covered service clsses. Obesity ssessment nd tretment cn be understood to fll in these covered ctegories. However, while eligible children re entitled to obesity ssessment nd tretment under EPSDT progrm regultions, it is not cler whether sttes re ctully covering necessry services. It ws hoped tht the 2004 CMS policy reversl would open the door to public nd privte coverge expnsions of evidence-bsed obesity-relted tretments. While more studies re needed to determine which therpies for obesity re most effective, tretment guidelines from the Ntionl Hert, Lung, nd Blood Institute nd other professionl orgniztions concur in supporting specific multidisciplinry pproches to tretment of obesity Despite these recommendtions, public nd privte insurnce coverge for tretment of obesity s primry disese still ppers very limited. Most coverge expnsions thus fr hve focused on britric surgery. CMS expnded coverge of britric surgery for Medicre beneficiries who re morbidly obese, but beneficiries must hve comorbid condition, such s hypertension, coronry rtery disese, osteorthritis, or type 2 dibetes. 22 Some privte insurers will lso cover britric surgery on limited bsis. 23 Few studies hve evluted public nd privte insurnce coverge of primry obesity tretment, especilly t the stte level. In this study, we exmined how sttes use their lwmking nd regultory uthority to respond to the problem of obesity. We conducted stte-by-stte nlysis of (1) Medicid nd EPSDT progrm coverge nd pyment prctices for dult nd peditric obesity ssessment nd tretment, (2) the extent to which sttes prohibit or regulte insurers medicl underwriting or eligibility exclusion of obesity, nd (3) the extent to which stte insurnce lws ddress coverge of obesity tretment. In previous studies of insurnce coverge for obesity tretment, reserchers utilized surveys to collect dt from privte insurers nd stte Medicid progrms. Our nlysis is bsed on n extensive document nd legl review of stte lws, regultions, nd provider guidnce. METHODS Medicid nd EPSDT progrm nlysis We reviewed current evidence-bsed guidelines for dult nd peditric obesity ssessment nd tretment We selected the following interventions for nlysis of Medicid coverge nd pyment prctices for dults with obesity: nutritionl ssessment/counseling, drug therpy, nd britric surgery. For children, bsed on current guidelines, we focused our serch on coverge nd reimbursement of nutrition nd behviorl therpies. Bsed on current tretment recommendtions,

3 598 Reserch Articles specific ntionl medicl service billing Current Procedurl Terminology (CPT ) codes for obesity ssessment nd tretment were selected (Figure 1). These codes would most likely be used in billing for the nutritionl, behviorl, nd surgicl therpies tht comprise the bulk of tretment pproches for obesity. 24,25 For ech stte, we reviewed Medicid provider mnuls, EPSDT progrm mnuls, codes nd regultions, nd fee schedules publicly vilble from stte websites. We limited our serch to Medicid fee-for-service documents nd excluded mnged cre service contrcts from our serch. 26 We reviewed provider mnuls for (1) provider guidnce for the ssessment nd tretment of obesity, (2) coverge nd reimbursement of specific obesityrelted tretments, nd (3) explicit exclusions of obesity-relted ssessment or tretment. Key word serches within these documents included obesity, weight, weight gin, morbid obesity, gstric bypss, Roux-en-Y, orlistt, sibutrmine, exentide, prmlintide, rimonbnt, gstroplsty, gstric djustble bnd, nutrition, diet, nd nutritionl services. We lso serched stte fee schedules for the selected CPT codes nd noted which codes were ssocited with reimbursement vlue. Results from our document review were compiled to grde ech stte bsed on whether their Medicid documents provided strong evidence, inconclusive evidence, or specific restrictions of provider reimbursement for obesity-relted tretments. Stte insurnce lw nlysis We reviewed stte lws nd regultions for privte insurnce in both the individul nd smll-group Figure 1. Selected billing codes used for obesity ssessment nd mngement CPT/HCPCS-II code Code description Obesity-relted service Helth nd behvior ssessments (helth-focused clinicl interview, behvior observtions, psychophysiologicl monitoring, helth-oriented questionnires) nd/or S9470 Counseling nd/or risk fctor reduction intervention (individul or group) Medicl nutritionl therpy (individul or group): nutritionl ssessment nd intervention by non-physicin provider Eduction nd trining for ptient self-mngement, by non-physicin Miscellneous services: physicin eductionl services to ptients in group setting S0315-S0316 Helth eduction disese mngement progrm: initil nd follow-up ssessments S9445-S9446 Ptient eduction, not otherwise specified Non-physicin provider, individul or group Helth nd behviorl intervention/ counseling Obesity prevention counseling Nutritionl counseling Counseling for individuls or groups of ptients with symptoms/illnesses Group counseling for ptients with symptoms/illnesses Helth eduction Helth eduction S9449 Weight mngement clss, non-physicin provider Weight mngement clss S9451 Exercise clss, non-physicin provider, per session Exercise clss S9452 Nutrition clss, non-physicin provider Nutrition clss Lproscopy, surgicl, gstric restrictive procedure Britric surgery with gstric bypss Lproscopy, surgicl, gstric restrictive procedure involving djustble gstric bnd Gstric restrictive procedure, without gstric bypss, for morbid obesity Gstric restrictive procedure with prtil gstrectomy Gstric restrictive procedure, with gstric bypss, for morbid obesity Revision, open, of gstric restrictive procedure The CPT code set, mintined by the Americn Medicl Assocition, is used by providers to bill for medicl services nd procedures. HCPCS Level II codes re used for products, supplies, nd services not included in the CPT codes. CPT 5 Current Procedurl Terminology HCPCS 5 Helth Cre Finncing Administrtion Common Procedure Coding Systems

4 Stte Obesity Tretment Coverge 599 mrkets (generlly three to 50 employees, though this vried by stte) for (1) sttutory provisions tht expressly prohibit or regulte medicl insurers medicl underwriting or eligibility exclusion prctices where obesity or helth sttus is used s n independent risk fctor nd (2) sttutory provisions mndting coverge of obesity- relted tretments. The 2004 CMS policy chnge llowed obesity to be considered medicl condition, nd, thus, considered under the term helth sttus. 14 We conducted stte-by-stte document review of stte insurnce lws nd regultions obtined vi Internet serch of the following websites: ech stte s Deprtment of Insurnce, Ntionl Assocition of Helth Underwriters, 27 Georgetown University Helth Policy Institute, 28 Ntionl Assocition of Insurnce Commissioners, 29 nd legl serches of stte insurnce codes from Westlw nd Lexis Nexis. We serched stte legislture websites for relevnt enrolled legisltion tht hd not yet been compiled into the officil stte code. Key words included obesity, weight loss, britric surgery, mndted coverge, nutritionl counseling, morbid obesity, gstric bypss, underwriting, risk fctors for underwriting, exclusions, nd preexisting conditions. RESULTS Specific guidelines for obesity ssessment nd tretment were rrely referenced in Medicid provider mnuls. Only two stte mnuls referenced ccepted tretment guidelines. Nebrsk nd South Crolin explicitly stte in their provider mnuls tht obesity is not n illness. Stte Medicid coverge of dult obesity tretment All stte Medicid progrms covered t lest one obesity tretment modlity. Eight sttes covered ll three tretment ctegories with vrious restrictions. Twentysix sttes explicitly covered nutritionl consulttion, while 20 explicitly did not. Drug therpy ws the lest frequently covered nd discussed tretment ctegory; only 10 sttes covered it, while 33 sttes mde no mention of it in their provider mnuls. Britric surgery ws the most frequently covered tretment (45 sttes); it ws lso the lest likely to be explicitly not covered (two sttes). Three sttes explicitly excluded nutritionl ssessment/counseling nd drug therpy, while covering britric surgery (Figure 2). Figure 2. Stte Medicid coverge of dult obesity tretment modlities Stte Nutritionl consulttion Drug therpy Britric surgery Albm b Alsk 1 b 2 1 c Arizon Arknss c Cliforni c Colordo 2 1 c 1 b Connecticut Delwre 1 c 1 c 1 c District of Columbi c Florid c Georgi c Hwii c Idho 1 b 0 1 b Illinois c Indin Iow 1 1 c 1 c Knss Kentucky Louisin Mine c Mrylnd c Msschusetts b Michign 1 b 0 1 b Minnesot 1 1 c 1 c Mississippi 1 1 c 2 Missouri 1 b 0 1 b Montn Nebrsk b Nevd b New Hmpshire b New Jersey New Mexico c New York b North Crolin b,c North Dkot 1 b 0 1 c Ohio c Oklhom b Oregon 1 b 0 1 c Pennsylvni c Rhode Islnd c South Crolin 1 b 1 c 1 b South Dkot b Tennessee Texs Uth c Vermont c Virgini 1 b 1 c 1 c Wshington 1 b 2 1 West Virgini b,c Wisconsin 1 b 1 c 1 c Wyoming c Bsed on n online document review of Medicid provider mnuls nd fee schedules s of July 1, 2008 b Vrious restrictions pply. c Preuthoriztion required 1 5 strong evidence for coverge 0 5 not mentioned/undetermined 2 5 specificlly excluded

5 600 Reserch Articles EPSDT coverge of peditric obesity tretment Most sttes published EPSDT-specific provider mnuls nd reimbursement informtion. Four sttes included detiled tretment stndrds for childhood obesity in their EPSDT provider mnuls. Nine sttes incorported detils on how to ssess or screen for child obesity in their EPSDT mnuls, but did not include guidelines on how to tret obesity. We found evidence tht 10 sttes will reimburse for nutritionl nd behviorl therpy in children. These sttes provided guidnce in their provider mnuls for the coverge of these services, s well s reimbursement mounts in their fee schedules for relted billing codes. Ten sttes did not ddress reimbursement of nutritionl ssessment nd tretment in their published mterils nd did not include relevnt CPT codes in their fee schedules. In these sttes, these services were not likely to be covered (Figure 3). The mjority of sttes provided some but not conclusive evidence tht they reimbursed for nutritionl ssessment nd counseling. In generl, these sttes either provided nonspecific guidnce regrding tretment for childhood conditions without listing relevnt billing codes, or they provided billing codes without ny specific lnguge directing providers to use these codes for nutritionl ssessment nd tretment in the setting of obesity. Figure 3. Stte Medicid EPSDT progrm coverge of recommended childhood obesity tretment Coverge of nutritionl nd/or behviorl therpy for obesity Likely to be covered Not likely to be covered Inconclusive Sttes Alsk, Arizon, Indin, Iow, Knss, Kentucky, Montn, New Mexico, Oklhom, Wshington Cliforni, Colordo, Hwii, Michign, Missouri, New Jersey, New York, Ohio, South Dkot, Texs Albm, Arknss, Connecticut, Delwre, District of Columbi, Florid, Georgi, Idho, Illinois, Louisin, Mine, Mrylnd, Msschusetts, Minnesot, Mississippi, Nebrsk, Nevd, New Hmpshire, North Crolin, North Dkot, Oregon, Pennsylvni, Rhode Islnd, South Crolin, Tennessee, Uth, Vermont, Virgini, West Virgini, Wisconsin, Wyoming Bsed on n online document review of Medicid provider mnuls nd fee schedules s of July 1, 2008 EPSDT 5 Erly nd Periodic Screening, Dignosis, nd Testing Regultion of privte insurnce mrket underwriting or exclusions In the smll-group mrket, nine sttes expressly prohibited the use of obesity s n independent risk fctor in medicl underwriting. Thirty-five sttes expressly llowed the use of obesity or helth sttus in djusting rtes within the smll-group mrket. The remining six sttes nd the District of Columbi were silent on this subject. In the individul mrket, only five sttes prohibited the use of obesity in medicl underwriting for both eligibility determintion nd for determining rtes becuse medicl underwriting ws prohibited in generl in these sttes. Oregon nd Wshington prohibited the use of obesity or helth sttus in determining rtes in the individul mrket. Oregon nd Cliforni expressly llowed the use of obesity or helth sttus in determining eligibility. Ten sttes llowed helth sttus to be used s fctor in setting rtes in the individul mrket, with only South Dkot specificlly mentioning weight s n llowble rting fctor. The remining sttes were silent on this subject (Figure 4). Regultion of privte insurnce coverge of obesity tretments In the group mrket, six sttes required or explicitly llowed insurers to offer coverge of certin obesity tretments. The sttutes did not specify group size. Only Uth expressly llowed britric surgery to be excluded from insurnce coverge. The rest were silent. In the individul mrket, five sttes required or explicitly llowed insurers to offer coverge of some obesity tretments. Illinois nd South Dkot explicitly llowed insurers to limit or exclude obesity tretments. Uth expressly llowed the exclusion of gstric bypss from coverge in the individul mrket. The remining stte codes nd regultions were silent (Figure 4). DISCUSSION The 2004 CMS revision of the Medicre Coverge Issues Mnul opened the door for obesity to be understood s medicl condition in its own right. 14 Public helth experts speculted tht the revision would led to expnded Medicre coverge of obesity-relted tretments, with privte nd public insurers following suit. Since then, Medicre s only expnsion hs been to cover britric surgery for beneficiries with comorbid conditions who meet specific criteri. Our reserch showed similr ptterns t the stte level. Most sttes re not using their sttutory or regultory uthority to expnd public nd privte insurnce coverge of obesity ssessment nd tretment. Our

6 Stte Obesity Tretment Coverge 601 Figure 4. Stte lws regrding privte insurnce coverge of obesity tretment nd underwriting bsed on obesity,b Medicl underwriting or exclusions bsed on obesity or helth sttus s n independent risk fctor Type of stte helth insurnce mrket nd restrictions Sttute expressly llows for rte djustments or exclusions Sttute expressly prohibits djustments in rtes or exclusions Smll-group mrket Rte setting Individul mrket Eligibility Individul mrket Rte setting Alsk, Arizon, Arknss, Cliforni, Colordo, Delwre, Florid, Idho, Illinois, Iow, Kentucky, Louisin, Michign, Minnesot, Mississippi, Missouri, Montn, Nebrsk, Nevd, New Hmpshire, New Mexico, North Crolin, North Dkot, Ohio, Oklhom, Rhode Islnd, South Crolin, South Dkot, Tennessee, Texs, Uth, Virgini, West Virgini, Wisconsin, Wyoming Cliforni, Oregon Cliforni, Idho, Kentucky, Louisin, Minnesot, Nevd, South Crolin, South Dkot, Texs, Uth Stte lws regrding coverge of one or more obesity-relted tretments Connecticut, Mine, Mrylnd, Msschusetts, New Jersey, New York, Oregon, Vermont, Wshington Mine, Msschusetts, New Jersey, New York, Vermont Mine, Msschusetts, New Jersey, New York, Oregon, Vermont, Wshington Sttute expressly prohibits coverge of obesity-relted tretment(s) Sttute expressly llows coverge of obesity-relted tretment(s) Smll-group mrket c Uth Georgi, Indin, Mrylnd, New Hmpshire, New Jersey, Virgini Individul mrket Illinois, South Dkot, Uth Georgi, Mrylnd, New Hmpshire, New Jersey, Virgini As of July 1, 2008 b Sttes not listed hd no relevnt sttute. c Sttutes for the six listed sttes llowing coverge of obesity-relted tretment do not specify group size. findings indicte only minority of sttes cover ll recommended therpies for obesity under Medicid or EPSDT. In the privte insurnce mrket, few sttes hve pssed legisltion requiring coverge of obesity tretments or protection ginst the use of obesity in medicl underwriting. In fct, some sttes expressly exclude coverge of certin obesity tretments or expressly llow obesity to be used in determining eligibility for insurnce coverge. Medicid coverge of recommended tretment for obesity Forty-five stte Medicid progrms cover britric surgery with vrious restrictions. This is consistent with other sources reporting tht 44 sttes covered gstric bypss surgery. 30 We found only 10 sttes tht explicitly covered weight-loss drugs under Medicid; the remining sttes were either silent on the issue or excluded weight-loss drugs. This is understndble becuse under federl lw, weight-loss drugs re one of the clsses of drugs tht Medicid progrms cn exclude from coverge. 31 However, our findings differ significntly from previous reports tht found nywhere from 17 to 38 sttes covered t lest one weight-loss drug under Medicid Most likely, these vritions re due to differences in methodology one report utilized survey of Medicid directors, nother reported dt provided by phrmceuticl compnies, nd the lst did not report the methodology used. We might expect to find fewer sttes with weight-loss drug coverge from our strict document review. We found evidence tht 26 stte Medicid progrms covered nutritionl ssessment nd consulttion for obesity. Our findings re generlly consistent with those of Tsi et l., who found tht eight out of 14 surveyed stte Medicid progrms offered consulttion with nutritionist or dietitin to their enrollees. 35 Almost ll the progrms Tsi nd collegues surveyed offered dietitin referrl only if the ptient hd n obesityrelted medicl condition. Eleven of the 26 sttes we found included vrious restrictions. We lso found 20 stte Medicid progrms tht explicitly exclude nutritionl services for enrollees. In contrst, the mjority of Medicid progrms will cover britric surgery for their enrollees, with restrictions. Surgery is lso less likely to be explicitly excluded

7 602 Reserch Articles under Medicid. Between 1998 nd 2002, the number of britric surgeries covered by Medicid incresed by more thn 260%. During the sme time period, surgeries finnced by Medicre incresed by more thn 280%, while those by privte insurers incresed by more thn 480%. 36 In covering britric surgery, stte Medicid progrms my be following the pttern of Medicre. However, prctice guidelines recommend tht clinicins screen ll dult ptients for obesity nd offer intensive counseling nd behviorl intervention to promote sustined weight loss for obese dults. It is interesting to note tht stte Medicid progrms continue to reimburse for expensive britric surgery, but often do not cover less invsive nd less expensive nutritionl or phrmcologicl therpies. Nutritionl nd behviorl counseling in overweight ptients cn decrese the incidence of future complictions such s dibetes. 37 Additionlly, lifestyle nd behviorl therpies re just s cost-effective s britric surgery, nd more effective thn drug therpy, lthough cost-effectiveness vries gretly bsed on the risk sttus of the popultion nd the type of intervention. 38,39 Despite evidence of effective primry tretments for obesity nd the hevy burden of obesity-relted complictions on Medicid progrms, there is very limited reimbursement for ssessment nd primry tretment of obesity. Even fter the CMS policy chnge, most stte Medicid progrms do not pper to be treting obesity s disese in its own right. Medicid coverge of childhood obesity ssessment nd tretment Childhood obesity is ssocited with significnt helth problems nd is n importnt erly risk fctor for much of dult morbidity nd mortlity. Thus, the potentil future helth-cre costs ssocited with peditric obesity nd its comorbidities re immense nd should not be ignored. Medicid-eligible children re entitled to ongoing nutritionl ssessment nd mngement, including obesity services, through the EPSDT progrm. Even when specific tretments for obesity re excluded for dults, Medicid requires prticipting sttes to cover EPSDT benefits for ll eligible children younger thn ge 21. In covering helth tretments for children, sttes re expected to dhere to stndrds of medicl necessity tht reflect ccepted peditric stndrds of cre. Evidence-bsed guidelines point to the importnce of regulr screening nd intensive behviorl nd dietry intervention erly in child s life to prevent nd reverse the deleterious effects of overweight nd obesity. All of the recommended prevention, ssessment, nd tretment guidelines should be covered s prt of the EPSDT benefit for eligible children. However, we found evidence tht only 11 sttes would cover obesity-relted nutritionl nd behviorl therpy through the EPSDT progrm. Even fewer sttes published ny detiled screening or tretment guidelines for childhood obesity for their providers. Despite the high prevlence of childhood obesity, mny physicins re not providing cre tht is consistent with recommendtions to prevent, screen, nd mnge childhood obesity. 40,41 Through the EPSDT progrm, sttes hve the sttutory directive nd infrstructure to trget high-risk peditric popultion nd promote evidence-bsed guidelines. Our findings indicte tht, unfortuntely, sttes re not fully leverging EPSDT progrms to fight childhood overweight nd obesity. Stte regultion of insurers obesity-relted prctices About 68% of Americns obtin helth-cre benefits through privte helth insurnce plns, mny of which re regulted t the stte level. 42 Some sttes require insurers to offer specific helth benefits or ccess to certin types of providers. Other stte regultions ffect the rting rules tht insurers use to set premiums or to evlute people for coverge through medicl underwriting. Privtely insured people re overwhelmingly insured in the employer-bsed group mrket, with only 6% of insured people covered through the individul mrket. 43 In the smll-group mrket, we found tht 41 sttes nd the District of Columbi either explicitly or implicitly llow insurers to use helth sttus or obesity s n independent fctor in determining rtes. Only nine sttes require smll-group helth plns to use community or n djusted community rting, where the premiums would be bsed on the expected clims of the community, not the individul employer group. These findings re consistent with the consumer informtion vilble from the Ntionl Assocition of Helth Underwriters. 27 Thus, in most sttes, n employer s helth insurnce premiums cn be ffected by the weight of his or her employees. Obesity crries high helth-cre costs; thus, s obesity rtes rise, incresing helth insurnce premiums my led employers to drop helth insurnce coverge, increse premiums nd cost-shring for employees, or lower wges for workers. In the individul mrket, medicl underwriting is prevlent, nd there is little regultion when it comes to determining eligibility for coverge nd rte setting. For exmple, survey by the Texs Office of Public Insurnce Counsel in 2007 found tht 100% of surveyed individul helth insurnce plns used body

8 Stte Obesity Tretment Coverge 603 mss index (BMI) s bsis to deny coverge, 86% used BMI to chrge higher premium, nd 14% used BMI to limit benefits. 44 We found tht in 45 sttes nd the District of Columbi, no legisltion protects individuls from being denied helth insurnce bsed on obesity or helth sttus. When it comes to rte setting, 43 sttes nd the District of Columbi llow rtes to be set bsed on helth sttus or obesity. If n obese ptient does mnge to obtin individul helth insurnce, there is no gurntee tht obesity-relted tretment would be covered under his or her helth pln. We found very few sttes tht mndted insurnce coverge of ny obesity-relted tretments. The mjority of stte codes re silent on the coverge of obesity tretment for both the group nd individul insurnce mrkets. Those sttes tht do require or llow insurers to offer coverge mention rnge of tretments from n nnul consulttion to discuss weight nd nutrition in New Jersey to coverge of britric surgery in Mrylnd Georgi llows insurnce compnies to offer coverge for non-experimentl forms of obesity therpy. 48 In short, despite the chnge in CMS policy regrding obesity, the privte insurnce mrket remins firly unregulted in regrd to the tretment of obesity s fctor in eligibility nd underwriting. Additionlly, very few sttes hve mndted privte insurnce coverge of obesity therpies. In fct, some sttes hve moved in the opposite direction, expressly llowing weight to be used s rting fctor or llowing insurers to not cover britric surgery. Limittions Other reserchers hve relied on surveys of helth plns or stte Medicid dministrtors to obtin coverge informtion. We conducted n extensive document review of current Medicid mnuls, fee schedules, stte insurnce codes, nd regultions. Our ssessment of coverge policy ws bsed solely on this written evidentiry review. If the ctul coverge policy or fee schedule for the tretment modlity ws misrepresented or not updted in the provider mnuls t the time of our review, we my hve scored the stte incorrectly. Therefore, our nlysis my hve been more stringent thn previous reserchers. However, our review lso reflected the ctul documented informtion regrding obesity tretment guidelines or coverge policy tht is publicly vilble to provider of Medicid or EPSDT services in the stte. We find it vluble for wht it revels in this regrd. Future studies compring results of our document review with surveys of helth plns or stte officils my be useful. In the dult Medicid nlysis, we limited our nlysis to coverge of nutritionl counseling nd did not include behviorl counseling, s there were limited dt on reimbursement of this service s it relted specificlly to obesity. We lso chose not to include mnged cre orgniztion (MCO) contrcts in our document review. In ccordnce with federl lw, most Medicid MCOs offer t lest the services covered under fee-for-service progrms. 49 However, s Tsi et l. found, some Medicid MCOs my offer dditionl services for obesity tretment tht stte Medicid progrms do not. 35 Thus, it is possible tht Medicid enrollees my hve ccess to more obesity tretment services through their MCOs thn we found in our study of fee-for-service progrms lone. CONCLUSIONS Our findings suggest tht most sttes re not ensuring recommended screening nd tretment of dults nd children for obesity through Medicid, the EPSDT progrm, or privte insurnce. Additionlly, most sttes re not regulting the insurnce mrket with regrd to use of obesity in medicl underwriting. With the current economic downturn, mny sttes re experiencing budget deficits nd re unlikely to expnd coverge of obesity tretments or enct coverge mndtes in the ner future. However, given the grve economic nd helth consequences of the growing obesity problem, sttes should recognize the need for stronger ction sooner rther thn lter. This study ws funded by Trust for Americ s Helth. The uthors thnk Lur Cohen for helping with reserch nd dt collection. References 1. Ogden CL, Crroll MD, Curtin LR, McDowell MA, Tbk CJ, Flegl KM. Prevlence of overweight nd obesity in the United Sttes, JAMA 2006;295: Colditz GA, Willett WC, Rotnitzky A, Mnson JE. Weight gin s risk fctor for clinicl dibetes mellitus in women. Ann Intern Med 1995;122: Hubert HB, Feinleib M, McNmr PM, Cstelli WP. Obesity s n independent risk fctor for crdiovsculr disese: 26-yer follow-up of prticipnts in the Frminghm Hert Study. Circultion 1983;67: Kurth T, Gzino JM, Rexrode KM, Kse CS, Cook NR, Mnson JE, et l. Prospective study of body mss index nd risk of stroke in pprently helthy women. Circultion 2005;111: Kurth T, Gzino JM, Berger K, Kse CS, Rexrode KM, Cook NR, et l. Body mss index nd the risk of stroke in men. Arch Intern Med 2002;162: Mokdd AH, Ford ES, Bowmn BA, Dietz WH, Vinicor F, Bles VS, et l. Prevlence of obesity, dibetes, nd obesity-relted helth risk fctors, JAMA 2003;289: Perry IJ, Wnnmethee SG, Wlker MK, Thomson AG, Whincup PH, Shper AG. Prospective study of risk fctors for development of non-insulin dependent dibetes in middle ged British men. BMJ 1995;310:560-4.

9 604 Reserch Articles 8. Dyer AR, Elliott P. The INTERSALT study: reltions of body mss index to blood pressure. INTERSALT Co-opertive Reserch Group. J Hum Hypertens 1989;3: Wolf AM, Colditz GA. Current estimtes of the economic cost of obesity in the United Sttes. Obes Res 1998;6: Office of the Surgeon Generl (US). The Surgeon Generl s cll to ction to prevent nd decrese overweight nd obesity. Rockville (MD): Deprtment of Helth nd Humn Services (US); Also vilble from: URL: obesity [cited 2008 Dec 12]. 11. Finkelstein EA, Fiebelkorn IC, Wng G. Ntionl medicl spending ttributble to overweight nd obesity: how much, nd who s pying? Helth Aff (Millwood) 2003;Suppl Web Exclusives:W Finkelstein EA, Fiebelkorn IC, Wng G. Stte-level estimtes of nnul medicl expenditures ttributble to obesity. Obes Res 2004;12: Hodge JG Jr, Grci AM, Shh S. Legl themes concerning obesity regultion in the United Sttes: theory nd prctice. Aust New Zelnd Helth Policy 2008;5: Deprtment of Helth nd Humn Services (US). HHS nnounces revised Medicre obesity coverge policy [news relese] 2004 Jul 15. Wshington: HHS; Also vilble from: URL: [cited 2009 Mr 20]. 15. Wilensky S, Whittington R, Rosenbum S. Strtegies for improving ccess to comprehensive obesity prevention nd tretment services for Medicid-enrolled children. Wshington: George Wshington University School of Public Helth nd Helth Services; October Also vilble from: URL: mdl=pubserch&evt= view&publictionid=3bb d20-3d751ecc597ce06c [cited 2009 Feb 10]. 16. Centers for Medicre & Medicid Services (US). The stte Medicid mnul: erly nd periodic screening, dignostic nd tretment services [cited 2009 Apr 16]. Avilble from: URL: Ntionl Hert, Lung, nd Blood Institute. Clinicl guidelines on the identifiction, evlution, nd tretment of overweight nd obesity in dults [cited 2009 Oct 1]. Avilble from: URL: Snow V, Brry P, Fittermn N, Qseem A, Weiss K; Clinicl Efficcy Assessment Subcommittee of the Americn College of Physicins. Phrmcologic nd surgicl mngement of obesity in primry cre: clinicl prctice guideline from the Americn College of Physicins. Ann Intern Med 2005;142: Eckel RH. Clinicl prctice. Nonsurgicl mngement of obesity in dults. N Engl J Med 2008;358: U.S. Preventive Services Tsk Force. Screening for obesity in dults: recommendtions nd rtionle. Ann Intern Med 2003;139: Brlow SE. Expert committee recommendtions regrding the prevention, ssessment, nd tretment of child nd dolescent overweight nd obesity: summry report. Peditrics 2007;120 Suppl 4:S Medicre nnounces finl coverge policy for britric surgery s dibetes tretment for certin individuls [news relese] 2009 Feb 12. Wshington: Deprtment of Helth nd Humn Services (US); Also vilble from: URL: medi/press/relese.sp?counter=3424 [cited 2010 Mr 10]. 23. Dvis MM, Slish K, Cho C, Cbn MD. Ntionl trends in britric surgery, Arch Surg 2006;141: Americn Acdemy of Peditrics. Obesity nd relted co-morbidities: coding fct sheet for primry cre peditricins [cited 2009 Mr 29]. Avilble from: URL: ObesityCodingFctSheet0208.pdf 25. Kpln LM, Fllon JA, Mun EC, Hrvey AM, Kstrinkis WV, Johnson EQ, et l. Coding nd reimbursement for weight loss surgery: best prctice recommendtions. Obes Res 2005;13: Rosenbum S. Negotiting the new helth system: purchsing publicly ccountble mnged cre. Am J Prev Med 1998;14(3 Suppl): Ntionl Assocition of Helth Underwriters. Stte-level helth insurnce mrket reforms [cited 2008 Jul 11]. Avilble from: URL: Georgetown University Helth Policy Institute. Consumer guides for getting nd keeping helth insurnce [cited 2008 Jul 11]. Avilble from: URL: Ntionl Assocition of Insurnce Commissioners. Mp of NAIC sttes nd jurisdictions [cited 2008 Jul 11]. Avilble from: URL: Perkins J. Ntionl Helth Lw Progrm. Coverge of gstric bypss surgery. September 2004 [cited 2008 Dec 10]. Avilble from: URL: Socil Security Act, 42 U.S.C. 1396r-8 (2007). 32. Crowley JS, Ashner D, Elm L; Kiser Commission on Medicid nd the Uninsured. Medicid outptient prescription drug benefits: findings from ntionl survey, Wshington: Kiser Fmily Foundtion; Also vilble from: URL: medicid/uplod/medicid-outptient-prescription-drug-benefits- Findings-from--Ntionl-Survey-2003.pdf [cited 2008 Dec 8]. 33. Americn Obesity Assocition. Medicid reimbursement for prescription weight-loss drugs [cited 2008 Dec 10]. Avilble from: URL: Trust for Americ s Helth. F s in ft: how obesity policies re filing in Americ [cited 2008 Dec 10]. Avilble from: URL: helthymericns.org/reports/obesity Tsi AG, Mnsukni S, Cucchir A, Schffer M. Avilbility of nutrition services for Medicid recipients in the northestern United Sttes: lck of uniformity nd the positive effect of mnged cre. Am J Mng Cre 2003;9: Encinos WE, Bernrd DM, Steiner CA, Chen CC. Use nd costs of britric surgery nd prescription weight-loss medictions. Helth Aff (Millwood) 2005;24: Knowler WC, Brrett-Connor E, Fowler SE, Hmmn RF, Lchin JM, Wlker EA, et l. Reduction in the incidence of type 2 dibetes with lifestyle intervention or metformin. N Engl J Med 2002;346: Bchmn KH. Obesity, weight mngement, nd helth cre costs: primer. Dis Mng 2007;10: Roux L, Kuntz KM, Donldson C, Goldie SJ. Economic evlution of weight loss interventions in overweight nd obese women. Obesity (Silver Spring) 2006;14: O Brien SH, Holubkov R, Reis EC. Identifiction, evlution, nd mngement of obesity in n cdemic primry cre center. Peditrics 2004;114:e Dorsey KB, Wells C, Krumholz HM, Concto J. Dignosis, evlution, nd tretment of childhood obesity in peditric prctice. Arch Peditr Adolesc Med 2005;159: DeNvs-Wlt C, Proctor B, Smith J, Census Bureu (US). Current Popultion Reports, P Income, poverty, nd helth insurnce coverge in the United Sttes: Wshington: U.S. Government Printing Office; August The Henry J. Kiser Fmily Foundtion. Updte on individul helth insurnce. August 2004 [cited 2008 Jul 1]. Avilble from: URL: Texs Office of Public Insurnce Counsel individul helth insurnce underwriting guidelines [cited 2009 Feb 16]. Avilble from: URL: Md. Code Ann., Ins (2008). 46. N.J.S.A. 17B: h (2008). 47. N.J.S.A. 17B: h (2008). 48. G. Code Ann (2008). 49. Socil Security Act of 1935, 42 U.S.C. Sect. 1396b.