Transcript Preventive Coverage

State-by-State Treatment of Obesity
Interventions
Christine Ferguson
Professor
George Washington University
School of Public Health and Health Services
Department of Health Policy
Director, STOP Obesity Alliance
The Research – Compiling Information in New Way
Bringing together comprehensive data on obesity-related coverage for all 50
states and the District of Columbia in a single place provides a unique way to
compare information.
» The GW research team compiled a comprehensive state-by-state survey of
obesity-related insurance regulation and coverage of services under Medicaid
and state employee benefit plans.
» Particular Areas of Focus:
– Lifestyle Programs (generally), e.g., gym memberships, Weight Watchers,
nutritional or other health related educational services
– Lifestyle Programs for Pregnant Women, e.g., risk assessment, nutritional
counseling, education on breast feeding
– EPSDT Services (Medicaid)
– Coverage for Co-Morbidities Associated with Obesity, e.g., diabetes,
hypertension, COPD, coronary artery disease, asthma, sleep apnea
– Coverage of Anti-Obesity Medications (Anorectics), e.g., Xenical, Meridia,
Phentermine
– Coverage of Bariatric Surgery, e.g., covered procedures and eligibility
requirements (BMI, presence of co-morbidity, failed attempts at weight
management through diet and exercise)
– Incentive Programs, e.g. reduction in cost-sharing as reward for maintaining a
specified health status factor, such as BMI or smoking cessation
A Research-Based Methodology for the Spectrum
of Coverage
» State Medicaid Policy:
– Title XIX State Plans
(Medicaid)
– State statutory and
regulatory provisions
related to coverage
for services
– State Medicaid agency
prior authorization
forms
– State Medicaid agency
prescription drug
formularies
– State Medicaid agency
member benefit
handbooks
» State Employee Benefit
Plans:
– Summary Plan
Documents for each of
the plans offering state
employee benefits
– Member handbooks for
each of the plans (if
necessary)
– Plan-specific prior
authorization
requirements for
bariatric surgery
– Pharmacy Benefit
Manager (PBM)
formulary and prior
authorization
requirements
State Insurance Mandates
»
»
»
Surveyed insurance
codes and regulations
related to small group
and individual health
plans
Focused on eligibility
and rate adjustments
that involved obesity or
health status
Focused on obesityrelated treatment (if the
state addressed this
issue at all, it was in the
realm of wellness and
prevention)
A Closer Look at What We Found:
Medicaid in Washington, District of Columbia
»
Preventive Services (Adults): May be available if
approved through prior authorization process
»
Preventive Coverage (Pregnant Women): Prenatal Care:
Services for any other medical conditions that may
complicate the pregnancy are provided with no limitation,
so long as the services are covered under Medicaid and
are related to the pregnancy
»
Preventive Coverage (Children up to age 21): EPSDT: If
nutritional assessment suggests a dietary inadequacy or
presence or risk of obesity, further assessment factors are
indicated:
– family, socioeconomic or community factors
– quality and quantity of individual diet
– physical and laboratory exams
– prevention, treatment, and follow-up services such as
dietary counseling and nutrition education
»
Coverage Related to Co-Morbidities: D.C. Medicaid does
not appear to offer a separate set of covered services for
chronic disease management.
A Closer Look at What We Found:
Medicaid in Washington, District of Columbia
(contd.)
»
Pharmaceutical Coverage
– Weight Loss Drugs: Weight loss drugs (Orlistat and
Sibutramine) require prior authorization. Will be
covered in three month increments if >3% weight loss
occurs for a maximum of one year.
‐ Eligibility Criteria: To receive weight loss drugs
an individual must be at least 12 years old and:
‐ have a diagnosis of BMI > 35 for Orlistat or
>27 for Sibutramine, or
‐ if co-morbidity present, the requisite BMI is
>30 for Orlistat, or >27 for Sibutramine;
‐ documented participation in a weight loss
program (including diet and exercise); and
‐ at least two previous attempts at weight
loss along with a clinical reason for their
failure
»
Surgical Coverage
– Covered Procedures: Gastric bypass requires written
justification and prior authorization through form
719A (the specific criteria for requesting gastric
bypass surgery is unavailable).
One Way the Research Can be Used:
Comparison of Medicaid Rx Coverage
CALIFORNIA
D.C.
NEW JERSEY
Medications indicated to induce
weight loss in obese
individuals are covered by
Medi-Cal with a showing of
medical necessity.
Xenical and Meridia require
prior authorization and
will be covered in three
month intervals if patient
sustains >3% weight loss
for a maximum of one
year.
Eligibility: Individual must be at
least 12 years old and
have
1) BMI >35 for Xenical; BMI
>27 for Meridia; or
2) If co-morbidity is present,
BMI >30 for Xenical and
BMI > 27 for Meridia
3) Documented participation
in weight loss program
(including diet & exercise)
4) At least two previous
attempts at weight loss
with documented clinical
reason for failure
Antiobesics and anorexiants are
excluded with the
exception of lipase
inhibitors limited to obese
individuals with:
1) BMI ≥27 and <30 with comorbidities of
hypertension, diabetes or
dyslipidemia;
2) BMI ≥30 without comorbidities
Medicaid will not cover more
than a 90-day supply of
these medications.
State-by-State Treatment of Obesity
Interventions
Christine Ferguson
Professor
George Washington University
School of Public Health and Health Services
Department of Health Policy
Director, STOP Obesity Alliance