Comprehensive Obesity Benefits Checklist

Obesity is a complex, expensive chronic disease that negatively impacts the health and longevity of more than 70 million Americans and imposes an enormous burden on our health care system and the economy. The need to confront the obesity epidemic calls for a serious look at how we address insurance coverage of obesity treatment. The present landscape of obesity care coverage is piecemeal. Health professionals frequently cite inconsistent and/or inadequate reimbursement for obesity-related services as a barrier to delivering appropriate care. Without guidance on how to operationalize evidence-based behavioral, nutritional, pharmacological and surgical obesity treatment modalities as health benefits, health care plans have taken vastly different approaches in determining what and how obesity treatment services are covered for their members. As a first step toward standardizing the availability of obesity care across plans, the STOP Obesity Alliance designed a Comprehensive Obesity Benefit that provides guidance on the core components of obesity care and the conditions under which these services and/or items ought to be covered. Our recommended benefit is broadly consistent with current evidence-based treatment guidelines and informed, in part, by current obesity benefit offerings across plan types and payers. Our benefit:

  1. Identifies evidence-based obesity treatment modalities that can support clinically significant weight loss among persons with obesity; and
  2. Provides guidance on the appropriate amount, scope, duration and delivery of obesity-related benefit offerings

Download the full Comprehensive Obesity Benefit (PDF).

 

Download: Comprehensive Obesity Benefits Checklist (PDF)

The Checklist

To align your benefits with the evidence provided in the Comprehensive Obesity Benefit, this checklist identifies the data needed to compare your plan(s) with the recommended benefit.

Screening and Prevention

  • Annual screening for obesity: document height, weight, waist circumference; calculate BMI
  • Annual screening for obesity-related comorbidities
  • Offer counseling on disease, diet and exercise

Intensive Behavioral Therapy (IBT)

  • Offer Intensive Behavioral Therapy (adults with BMI > 30, waist circumference ≥ 40 inches in men ≥ 35 inches in women, or BMI 25-29 with obesity related comorbidities) with a clinician 12-26 sessions annually, additional visits as needed with prior authorization
    • Offer physical activity plan that includes personalized recommendations 150min/week goal adapted for patient’s capacity
  • Nutritional Therapy with dietician
    • Initial assessment + up to 14 visits annually; continue therapy for at least 6 months

 

Pharmacotherapy

  • Cover all FDA-approved medications (short-term and long-term) for patients with BMI ≥ 27 w/ obesity related comorbidity or a BMI ≥ 30 valudated through a Prior Authorization

Bariatric Surgery

  • Cover one primary procedure when BMI ≥ 40 or BMI ≥35 with weight related comorbidity or BMI ≥ 30 with type 2 diabetes with a comprehensive pre/postoperative treatment plan established, and no medical contraindications to the procedure
    • Primary bariatric procedures include: Roux-en-Y gastric bypass, Sleeve gastrectomy, Gastric banding, Duodenal switch, and Intragastric balloon
  • Cover 1+ revisional procedure to correct complications or when weight loss is inadequate despite adherence to prescribed post-op treatment regimen

Weight Maintenance

  • On-going tracking and documentation of weight status (waist circumference; BMI), changes in weight status (% change in body weight), and body weight concerns

    • 2 visits per year minimum, 1 with dietician, 1 with primary care physician