Medicaid Coverage for Weight Loss Drugs and Gastric Bypass Surgery
June 2004
Medicaid coverage of weight-loss drugs
Weight-loss drugs are one of nine classes of drugs that Medicaid programs can exclude from coverage under federal law. (Note that under the Early and Periodic Screening and Treatment provisions of Medicaid law, even if this drug coverage is excluded for adults, states may need to provide weight-loss drugs when appropriate for children.)
Medicaid Law: Limitations on Coverage of Drugs SSA§1927(d)(2):
(2) LIST OF DRUGS SUBJECT TO RESTRICTION.—The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted:
(A) Agents when used for anorexia, weight loss, or weight gain….
In 2003, 23 states excluded weight loss drugs from Medicaid coverage.¹ However, totally excluding the drug coverage can put states in the position of paying for expensive bariatric surgery without covering less expensive and invasive treatment. This sort of problem led Virginia to modify its policy in 1999 to allow coverage of weight-loss drugs for people meeting disability standards for obesity, and whose condition is certified as being life-threatening. (See http://leg1.state.va.us/cgi-bin/legp504.exe?000+reg+12VAC30-50-520)
Medicaid coverage of weight-loss surgery
A memorandum describing Medicaid law and case law, Jane Perkins, “Coverage of Gastric Bypass Surgery,” National Health Law Program, September 24, 2004, is on the website www.healthlaw.org (search in “library.”) In summary, federal Medicaid law does not mention coverage of gastric bypass surgery specifically; however, the components of the surgery—inpatient hospital and physician services—are required Medicaid services. States may not arbitrarily deny or reduce the amount, duration and scope of a required service solely because of the diagnosis, type of illness or condition, (42 CFR § 440.230(c)), but states can place limits on services that are based on such criteria as “medical necessity or on utilization control procedures” (42 CFR § 440.230(d)). Individual cases about Medicaid coverage of gastric bypass surgery generally involve proving that for a particular patient, the surgery is medically necessary and not cosmetic. This might involve looking at a person’s body mass index, weight, and other health problems, referencing alternative treatments that the patient has tried, and noting likely improvements in the patients’ health and functional abilities that will result from weight loss.
State Medicaid agencies and state Medicaid administrative hearing officials may be influenced by other insurers’ coverage decisions in determining whether Medicaid should cover gastric bypass surgery. Some useful websites about this are as follows:
According to Dr. Susan Beane, Medical Director of Affinity Health Plan and a member of the New York Health Plan Association work group, a number of questions about best medical practices concerning obesity were arising in New York prior to the issuance of the work group’s consensus guidelines. These included:
- How do you prepare someone for surgical management of obesity? What treatment should they receive after surgery?
- What prior experience should the surgeon have – how many people do qualified surgeons treat?
- For what patients is bariatric surgery (that is, weight loss surgery) appropriate?
- Treatment of adolescents and people over the age of 65 is controversial – how should it be handled?
The medical community was relying heavily on a 1991 NIH guideline which had not been updated. Therefore, medical directors of a number of health plans convened to examine more current research and then issue consensus guidelines about best practice for bariatric surgery.
There was no consensus about whether psychiatric counseling should be a requirement for people undergoing bariatric surgery or about the length of time people should try other treatment before considering surgery. Many surgeons do advise an evaluation before surgery, but there is no particular research about this. It is not advisable to rush into treatment, Dr Beane reported. Before surgery, patients should review and practice dietary requirements and patients and their doctors should talk through the possible outcomes of surgery. Patients also need to be aware of the huge lifestyle changes that will have to take place post-operation. The surgery has a long and slow recovery period. Many surgeons state that they will want to observe that their patients can maintain or lose some weight before the surgery, which may lead to a more promising outcome.
In determining whether a patient is a good candidate for surgery, the focus is usually on the patient’s own history rather than the family history. The patient’s Body Mass Index (BMI), medical history, and documentation of weight loss attempts are relevant.
This fact sheet was prepared from notes of a Health Assistance Partnership conference call. Dr. Susan Beane was the main speaker and participants included staff of Medicaid consumer assistance programs.
¹ See J. Crowley, D. Ashner, and L. Elam, “Medicaid Outpatient Prescription Drug Benefits: Findings from a National Survey, 2003” (Kaiser Family Foundation, December 2003). Table 3 lists state prescription drug exclusions and Table 8 lists drugs subject to state pre-authorization.
