Medicaid Obesity Treatment Coverage 2024

The STOP Obesity Alliance partnered with the Obesity Action Coalition to analyze how states are covering the treatment of obesity in their Medicaid programs. The review of Medicaid coverage included the elements of comprehensive obesity care: nutrition counseling (NC), intensive behavioral therapy (IBT), obesity medications (OM), and metabolic and bariatric surgery (MBS). These data were extracted from Medicaid manuals, fee schedules, statutes, regulations, preferred drug lists, and managed care coverage when available. 

State data include:

(1) State population from the U.S. Census Bureau; (2) Prevalence of adult obesity and adult diabetes from the 2022 Centers for Disease Control’s Behavioral Risk Factor Surveillance System, the latest published data available at the time of this coverage review; (3) Medicaid coverage rate, which is the percent of total state population on Medicaid taken from state Medicaid websites.

 Project Methodology

Download the Medicaid Obesity Coverage project methodology (PDF).

Methodology for State Medicaid Obesity Treatment Coverage 2024

This study is a review of how states’ policies cover the treatment of obesity in Medicaid programs. The data and analysis provide insight into the categories of obesity treatments offered and the level of coverage by state Medicaid programs.

The review of Medicaid coverage included the elements of comprehensive obesity care: nutrition counseling, intensive behavioral therapy, obesity medications, and metabolic and bariatric surgery. The top Managed Care Organization (MCO) and Fee for Service (FFS) plans for each state’s Medicaid program were reviewed for this study. The analysis is a combination of both MCO and FFS for each state.

Source Data

We contracted with LEVERAGE, a solutions and consulting firm, to extract the state Medicaid coverage data for plan year 2023. LEVERAGE provided the data and information for each state’s Medicaid program from their proprietary resource – AXIACI – which focuses on structural and organizational characteristics of programs and plan coverage details.

LEVERAGE extracted the data using the AXIACI platform, which includes source library, market segmentation, existing entity attributes and state and carrier profiles.

• States were segmented based on existing AXIACI attributes describing their statutory and organizational structure such as whether they had a managed care program, whether they carved pharmacy benefits out of managed care contracts and whether they employed uniform drug lists and uniform coverage criteria. 
• For each state, the appropriate source materials and documents necessary to determine coverage and coverage criteria were identified.  Examples included statutes, regulations, MCO and pharmacy benefit manager (PBM) contracts.
• At the MCO and FFS levels, the materials used to determine coverage included provider manuals, medical and pharmaceutical coverage criteria policies, fee schedules, preferred drug lists, web-site information and other available materials.

For this dataset, LEVERAGE developed and tested standardized attributes and values that affect patient access and coverage for the identified obesity treatments such as

• Overall state Medicaid coverage decisions on specified obesity treatments,  
• Boundaries to coverage not related to medical necessity –i.e., lifetime limits on bariatric and metabolic surgeries, prior weight loss efforts, specification of provider types, site of care requirements; and
• Medical Necessity Criteria – i.e., BMI levels, specified co-morbid conditions, and definition of surgical complications.  

Study Methodology

The extracted data were explored to determine the level of coverage provided for each treatment category. The detail provided by LEVERAGE allowed us to categorize the data based on whether a benefit was covered or not covered, covered with limitations, and/or covered with restrictions. Only coverage of adults was considered in this study. 

For purposes of this study, limitations and restrictions describe the barriers to access covered treatments. We defined a limitation to treatment as a criterion that must be met at the patient level, usually a clinical parameter or provider decision to access a treatment. A restriction was defined as an administrative barrier that does not follow evidence-based care and further blocks access to treatments. 

We developed a novel scoring approach to analyze the level of obesity treatment coverage. Each obesity treatment category was assigned a value according to the level of coverage provided. Each state was then assigned a final value based on the categories assessed and the total score. The final values reflect whether overall obesity treatment in the state was covered, covered with limitations, covered with restrictions, or not covered. 

Below are each of the coverage categories with an explanation of the values used for scoring.

Coverage Categories

Nutrition Counseling (total value= 2)

Nutrition counseling (NC) was given a total value of “2”. 

Few states were explicit about NC for obesity treatment unless it was tied to metabolic and bariatric surgery requirements. Fee schedules were used to interpret coverage where necessary.

• “Covered” – Nutrition counseling is covered (value = 2)
• “Not Covered” – Nutrition counseling is "non-scheduled" or no obesity-specific codes or general codes that could be used to bill for obesity services were indicated as covered on the fee schedule, or nutrition counseling covers only non-adults (value = 0)

Intensive Behavioral Therapy (total value= 2)

Intensive behavioral therapy (IBT) for treatment of obesity was given a total value of “2”. 

Few states were explicit about this coverage; therefore, fee schedules were used to interpret coverage where necessary. States will often cover IBT but not always cover it explicitly for obesity treatment.
“Covered” – IBT is covered and the data include codes for IBT allowed for obesity treatment (value= 2)

• “Covered with restrictions” – IBT is covered by Medicaid, but there are no obesity codes mentioned (value= 1)
• “Not covered” – IBT is not covered (value= 0)

Obesity Medications (total value = 4)

Medications that are covered for the specific purpose of treating obesity (not to treat Type 2 diabetes with obesity as a secondary condition) were given a total value of “4”. 

The medications covered for obesity were reviewed from the state Fee for Service and the top Managed Care Organization Prescription Drug List. The obesity medications (OM) considered were the new generation medications, including Saxenda and Wegovy, and the older generation medications, including Contrave, Qysmia, Phentermine, Benzphetamine, Diethylpropion, and Phendimetrazine. Xenical, Orlistat and Alli are older generation medications that are now available over the counter. At the time of this study, Zepbound was not yet on the market for the treatment of obesity.

• “Covered” – The state will cover medication for the specific purpose of treating obesity (not to treat Type 2 diabetes with obesity as a secondary condition). There are no limitations or restrictions to coverage, and the state offers at least one drug from both the new generation (Saxenda and Wegovy) and older generation (Contrave, Qysmia, Phentermine, etc.) medication categories (value = 4)
• “Covers limited medications” – The state only covers medications, without limitations or restrictions, from either the new generation (Saxenda/Wegovy) or the older generation of drugs (Contrave/Qysmia/Phentermine, etc.) categories (value = 3)
• “Covered with limitations” - if all OMs are covered but there are limitations to coverage (value= 3) 
  The limitations  for OM coverage include:
  • “BMI”
  • “Age”
  • “Co-morbidity regardless of BMI”
  • “Medical necessity conditions”
  • “Designated program”
• “Covered with restrictions” - if all OMs are covered but there are restrictions to coverage (value= 2) 
  The restrictions for OM coverage include:
  • “Third party entity for evaluations”
  • “Proof of failed attempts”
  • “Time”
  • “Renewal”
  • “Renewal Weight Loss”
• “Covered with limitations and restrictions” – if all OMs are covered but there are both limitations AND restrictions to coverage (value = 1)
• “Not covered – covers only medications that can be bought over the counter” – only medications that are available to purchase of the counter, such as Orlistat/Xenical/Alli, are covered (value = 1)
• “Not covered” – no medications are covered for the specific purpose of treating obesity (value = 0) 

Metabolic Bariatric Surgery (total value = 4)

Coverage of metabolic and bariatric surgery (MBS) was given a total value of “4”.

• “Covered” – MBS is covered, and if a BMI value for coverage is available, it follows the American Society for Metabolic and Bariatric Surgery guidelines. These guidelines specify that metabolic and bariatric surgery should be covered for a person with a BMI of >35 or a BMI > 30 with at least one comorbidity (value = 4)
• “Covered with limitations” – MBS is covered, but there are limitations to the coverage - (value =3) 
  The limitations for MBS coverage are:
  • “Age”
  • “BMI”
  • “Comorbidity regardless of BMI” 
  • “Qualifying comorbidities” 
  • “Center of Excellence requirement” 
  • "Provider restriction
• “Covered with restrictions” – MBS is covered, but there are restrictions to obtaining coverage (value= 2)
  The restrictions for MBS are:
  • “Documentation of weight loss attempt”
  • “Number of weight loss attempts”
  • “Obesity minimum duration”
  • “Length of weight loss attempt”
  • “Recency of weight loss attempt”
  • “Weight loss program required”
  • “Limitations on revisions and corrections”
  • “Revisions/corrections post-op non-compliance”
  • “Revisions/corrections inadequate weight loss”
  • “History of substance use disorder”
  • “Mental health evaluation” 
• “Covered with both limitations and restrictions” (value = 1)
• “Not-covered” – metabolic and bariatric surgery is not covered (value = 0)

Final Scores

The scores for each state were totaled based on the values they received from the above categories. 
Each state was assigned a final value. The final values reflect whether overall obesity treatment in the state was covered, covered with limitations, covered with restrictions, or not covered. The total possible value was “12”. 

Covered = States that scored a total value of “10-12” 

Limited Coverage = States that scored a total value of “7-9” 

Restricted Coverage = States that scored a total value of “4-6” 

Not Covered = States that scored a total of “0-3”

Detailed Descriptions of Limitations and Restrictions.

Download the Detailed Description of the limitations and restrictions (PDF).

Nutrition Counseling (NC) Coverage Definitions
Covered	The state covers nutrition counseling. Fee schedules have been used to interpret coverage where necessary because few states were explicit about nutrition counseling coverage for obesity unless tied to metabolic and bariatric surgery requirements.
Not Covered	Not covered means that nutrition counseling is “not scheduled” and no obesity-specific codes or general codes that could be used to bill for obesity services were indicated as covered on the fee schedule.

 

Intensive Behavioral Therapy Coverage (IBT) Definitions
Covered	The state covers intensive behavioral therapy. Few states were explicit about this coverage.  In states with no explicit coverage, fee schedules have been used to derive coverage.
Covered with limitations	No obesity-specific codes or general codes that could be used to bill for obesity services were indicated as covered on the fee schedule.
Not Covered	Intensive behavioral therapy is not covered.

 

Obesity Medication Coverage (OM) Definitions
Covered	The state will cover obesity medications for the specific purpose of treating obesity (not to treat Type 2 diabetes with obesity as a secondary condition). There are no limitations or restrictions to coverage, and the state offers both new generation (Saxenda and Wegovy) and older generation (Contrave, Qysmia, Phentermine, etc.) medications. The drugs covered for obesity were reviewed from the state fee for service (FFS) and the managed care organization (MCO) Prescription Drug List (PDL) of the MCO with the greatest number of enrollees. The drugs that were considered include: Saxenda, Wegovy, Xenical, Alli, Contrave, Qysmia, Phentermine, Benzphetamine, Diethylpropion, and Phendimetrazine.
Covers only limited medications	The state only covers medications, without limitations or restrictions, from either the new generation (Saxenda/Wegovy) or the older generation drug (Contrave/Qysmia/Phentermine, etc.) categories.
Covered with limitations	The state will cover obesity medications for the specific purpose of treating obesity, and all obesity medications are covered (both new generation and older generation) but there are limitations to coverage overall and criteria that must be met at the patient level.
OM Limitations	Definitions
BMI	The state has specified the body mass index (BMI) criteria a patient must meet.
Age	There are restrictions on coverage based on age. (Coverage for adolescents is not included for purposes of this research).
Comorbidity regardless of BMI	The patient must have a diagnosis of at least one from a list of specified comorbidities in addition to meeting a minimum defined BMI value.
Medical necessity conditions	There are specific criteria an individual patient must meet for the state to cover the obesity medication.
Designated program	The patient must participate in a designated program for coverage (i.e., group therapy, exercise, counseling, regular medical monitoring).
Covered with restrictions	The state will cover medication for the specific purpose of treating obesity as long as specified criteria are met.
OM Restrictions	Definitions
Third party entity for evaluations	The state has contracted with a third-party entity to manage utilization of obesity medication and process claims.
Proof of failed attempts	The patient must provide documentation of participation in a structured weight loss program within a specific period of time prior to request for coverage.
Time	There is a time frame for initiation of obesity medication after which renewal must be approved.
Renewal	There are conditions for approval of renewal of the medication.
Renewal weight loss	The patient must achieve a specific amount of weight loss for the medication to be renewed.

 

Metabolic and Bariatric Surgery (MBS) Coverage Definitions
Covered	The state includes coverage for metabolic and bariatric surgery (MBS). If a BMI value for coverage is available, it follows the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines for surgery (MBS should be covered for a person with a BMI >35 and BMI >30 and above with at least one comorbidity).
Covered with limitations	The state includes coverage for metabolic and bariatric surgery, however there are limitations to coverage.
MBS Limitations	Definitions
Age	There are restrictions on coverage based on age, i.e. only 18-64y is covered, <21y is not covered, or >65y is not covered. (Coverage for adolescents is not included for purposes of this research)
Body Mass Index (BMI)	The state has specified the BMI criteria the patient must meet and the criteria exceeds the current ASMBS guidelines (which are >35 or >30 with a comorbidity).
Comorbidity regardless of BMI	The patient must have a diagnosis for at least one comorbidity regardless of BMI for coverage.
Qualifying comorbidities	The specific comorbidities, or types of comorbidities, the state has defined with which a patient must have a diagnosis to meet the criteria for coverage.
“Center of Excellence” requirement	For a metabolic and bariatric surgery procedure to occur, provider must practice at a “center of excellence” established or defined by the state.
Provider restriction	Restricts the type of provider that is required to perform metabolic and bariatric surgery.
Covered with restrictions	The state includes coverage for metabolic and bariatric surgery but there are restrictions to coverage including criteria that a patient must meet to ensure surgery will be covered.
MBS Restrictions	Definitions
Documentation of weight loss attempt	The patient is required to document previous weight loss attempts.
Number of weight loss attempts	The patient is required to document the number of previous weight loss attempts.
Obesity minimum duration	The patient is required to have had a diagnosis of obesity for a minimum period of time in order to meet the criteria for metabolic and bariatric surgery approval.
Length of weight loss attempt	The patient is required to have a certain length of time spent on alternative weight loss programs.
Recency of weight loss attempt	There is a length of time in the recent past within which the patient must have attempted weight loss (i.e., within the past 18 months).
Weight loss program required	The patient is required to participate in a structured weight loss program before metabolic and bariatric surgery.
Limitations on revisions and corrections	The state has established limits on the number or type of revision of original metabolic/ bariatric surgical procedure it will cover, such as lifetime limitation on number of related surgeries, or exclusion of revisional surgeries – only those to correct a complication caused by the initial surgical procedure.
Revisions and corrections post-op non-compliance	The criteria that must be met for a repeat bariatric and metabolic surgery to be approved includes a requirement that the patient (and/or provider) provide proof of compliance with all previously prescribed postoperative nutrition and exercise programs. In other words, the patient must prove that the complications were not caused by “overeating” or any other non-compliant behavior after the first procedure.
Revisions and corrections inadequate weight loss	Inadequate weight loss is one of the criteria used to determine whether a correction or revision to metabolic and bariatric surgery will be covered, if the patient provides proof they complied with the nutrition and exercise program postoperative requirements after the first surgery,
History of substance use disorder	A patient could be excluded from coverage if there is a history of substance use disorder (SUD) now or in past; some states exclude patients with a SUD within a certain time, i.e. 18 months, and some exclude patients who have ever had a SUD.
Mental health evaluation	The patient is required to be evaluated by a mental health professional prior to approval of metabolic and bariatric surgery.

 

Read the 2020-21 State Employee Health Plan Obesity Treatment Coverage report Explore 2016-2017 Obesity Medicaid Coverage