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Obesity, Medicaid and Medicare |
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Medicaid does not cover obesity. Under Medicare, hospital and physician services to treat obesity are excluded unless the treatment is for certain co-existing conditions, and then it is considered on a case by case basis. Medicaid
is a government program that provides health insurance to
qualified individuals whose income level is below a certain
point. Recipients of Medicaid are primarily women and children
who are poor and members of minority groups. Given the high
prevalence of obesity among those populations, it could be
presumed that many Medicaid recipients are likely to have
obesity. Medicare provides health insurance coverage to elderly
citizens and disabled Americans who qualify by meeting criteria
of the Social Security Administration (SSA) and completing
a two-year waiting period.
Medicaid
- In
1990, Congress enacted the Omnibus Budget Reconciliation
Act (OBRA), which funds state programs to provide pharmaceutical
products to Medicaid recipients.
- A
State may choose to exclude or restrict drugs or classes
of drugs, or their medical uses for certain purposes.
A State choosing to include outpatient drugs within its
Medicaid program must cover, for their medically accepted
indications, all Food and Drug Administration (FDA) approved
prescription drugs of manufacturers that have entered into
drug rebate agreements, with a few limited exceptions.
- Exceptions
include drugs when used for: anorexia, weight loss
or weight gain; to promote fertility; for cosmetic purposes
or hair growth; for the symptomatic relief of cough and
colds; or to promote smoking cessation.
- As
a result of OBRA, the Department of Health and Human Services
ordered states to cover Viagra for the treatment of erectile
dysfunction while continuing to exclude anti-obesity agents.
Medicare
- In July 2004, the Department of Health and Human Services eliminated Medicare policy previously stating that obesity was not a disease. The Medicare Coverage Manual defines obesity and the justification for its treatment coverage by stating that:
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Obesity may be caused by medical conditions such as hypothyroidism, Cushing¹s disease, and hypothalamic lesions or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Services in connection with the treatment of obesity are covered services when such services are an integral and necessary part of a course of treatment for one of these medical conditions. However, program payment may not be made for the treatment of obesity unrelated to such a medical condition since treatment in this context has not been determined to be reasonable and necessary.
- This does not change any of the current coverage determinations. Treatments for obesity alone remain non-covered and coverage for treatments of diseases resulting in or exacerbated by obesity remain unchanged.
- Individuals wishing to modify current coverage determinations are encouraged to request a National Coverage Determination on each specific treatment. The web site of the Centers for Medicare and Medicaid Services offers guidance on the Medicare Coverage Process Regulations.
- For more information on the recent changes in Medicare policy, read the AOA's Medicare and Obesity: Frequently Asked Questions.
- Medicare’s
limited coverage of obesity is difficult to understand when
considering that it does cover services such as inpatient
and outpatient alcohol detoxification and rehabilitation,
inpatient and outpatient drug rehabilitation, and services
for sexual impotence. It also covers chemical aversion therapy
for the treatment of alcoholism even though the FDA has
not approved the drugs commonly used in chemical aversion
therapy for this application.
Supplemented Fasting
On
supplemented fasting, the Medicare Coverage Manual states
that:
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Supplemented fasting is a type of very low calorie weight
reduction regimen used to achieve rapid weight loss. The
reduced calorie intake is supplemented by a mixture of protein,
carbohydrates, vitamins and minerals.
- Serious
questions exist about the safety of prolonged adherence
for two months or more to a very low calorie weight reduction
regimen as a general treatment for obesity, because of instances
of cardiopathology and sudden death, as well as possible
loss of body protein. Therefore, supplemented fasting is
not covered as a general treatment for obesity.
- In
cases where weight loss is necessary before surgery in order
to ameliorate the complications posed by obesity when it
coexists with pathological conditions such as cardiac and
respiratory diseases, diabetes or hypertension (and other
more conservative techniques to achieve this end are not
regarded as appropriate), supplemented fasting with adequate
monitoring of the patient are covered under Medicare on
a case-by-case basis, as determined by your medical consultant.
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The risks associated with the achievement of rapid weight loss
must be carefully balanced against the risk posed by the condition
requiring surgical treatment.
Gastric Bypass Surgery
Surgery for the treatment of obesity is covered on a limited
basis. According to the Medicare Coverage Manual:
- gastric
bypass surgery, which is a variation of the gastrojejunostomy,
is performed for patients with extreme obesity. Gastric
bypass surgery for extreme obesity is covered under the
program if:
- it
is medically appropriate for the individual to have such
surgery.
the
surgery is to correct an illness, which caused the obesity
or was aggravated by the obesity.
Medicare Pharmaceutical Proposal
- In December, 2003, President Bush signed into law a new outpatient prescription drug benefit that will be available in 2006. The benefit will not include drugs for the treatment obesity.
- The AOA lobbied for several years for the inclusion of obesity treatment drugs in the benefit plan, and continues to do so for consideration in amendments to the plan.
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