So what is the best health insurance for weight loss? If losing weight were easy, everybody would be thin, right?
Best Health Insurance for Weight Loss
Unfortunately, it isn’t easy. Millions of Americans are overweight, and have trouble dropping the weight and keeping it off. But If you’re severely overweight, losing weight is likely an imperative if you want to maximize both your longevity and your quality of life.
This guide will help you understand your options, how to find a health plan that works for you and will help you lose the extra pounds, and help show you how to make the most of the available plan benefits.
Obesity’s a Big Problem (No Pun Intended)
Obesity is a widespread and pressing issue affecting millions of Americans. According to the Centers for Disease Control and Prevention (CDC), over 42% of U.S. adults are classified as obese, with an additional 32% considered overweight.
In other words, nearly 2/3rds of the U.S. adult population is overweight. And the numbers are even more terrible for those aged 40 and up.
This epidemic has far-reaching implications for individuals and society as a whole.
The costs associated with obesity are staggering. Obesity is linked to numerous comorbidities, including diabetes, heart disease, stroke, and certain cancers, significantly increasing mortality rates. For individuals, this often translates to higher out-of-pocket medical expenses, more frequent time off work, and increased risk of disability.
The CDC estimates that annual medical costs for people who are obese are $1,429 higher than those of normal weight.
The economic impact of obesity extends beyond individuals to employers and the broader economy. According to the Society for Human Resource Management (SHRM), obesity-related absenteeism costs U.S. employers an estimated $4.3 billion annually. Additionally, obesity can lead to higher health insurance premiums and increased workers’ compensation claims, further burdening employers.
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ACA-Qualified Health Insurance and Weight Loss Coverage
Weight Loss Counseling and Education
The good news is that all ACA-qualified health insurance plans now cover weight loss screening and counseling without a deductible or copay.
These counseling sessions can help you identify any triggers or stressors that may be contributing to your weight problem or overeating, and help you learn better eating habits and things you can do to burn calories and keep your metabolism fired up, so you can burn more calories.
Prescription Weight Loss Drugs
ACA-qualified health insurance plans often cover prescription weight loss drugs. These medications are typically prescribed for individuals with a BMI of 30 or higher, or a BMI of 27 if you also have related comorbidities such as diabetes or hypertension.
These covered medications may include popular options like phentermine, orlistat, and liraglutide (Saxenda).
Every health plan has a formulary – that is, a list of covered drugs, which is publicly available information. If your doctor recommends a specific drug, take a look at your plan’s formulary and see how your plan covers it.
Note that coverage can vary significantly between plans. Some insurers may require prior authorization, which means your doctor must provide documentation that the medication is medically necessary before the plan will approve the expense. Additionally, there may be limitations on the duration of coverage for these medications.
Wegovy and Ozempic
Wegovy (semaglutide) and Ozempic (semaglutide) are two very popular and effective medications initially approved for managing type 2 diabetes but are also effective for weight loss.
Both belong to a class of drugs called GLP-1 Receptor Agonists that help people produce insulin to lower the amount of sugar in their blood. These drugs work by slowing down movement of food through the stomach and suppressing appetite.
When combined with a lower-calorie diet and exercise, they have proven very effective in lowering a1c levels in diabetics, as well as in helping patients reduce weight.
A recent study showed that Wegovy can reduce the risk of stroke or cardiovascular death in obese patients by up to 20% compared to those receiving a placebo.
Additionally, studies show that most people on Wegovy successfully lost weight –– about 10% of their body weight, on average, over in the first 15 months of using the medication. They also sustained their weight loss over four years when continuing to take Wegovy.
As a result, Wegovy has recently received FDA approval for use in controlling obesity and overweight.
The problem: Both Wegovy and Ozempic are extremely expensive. Without insurance, the cost of a one-month supply of Ozempic approaches a thousand dollars. And Wegovy runs as high as $1,349.02 per month–– more than $16,188 per year. Which makes insurance companies extremely averse to covering it, in most cases.
Many private insurance plans cover Wegovy and Ozempic specifically for diabetes management. However, it can be much more difficult to get your insurance to cover these medications specifically for weight loss if you don’t also have a diabetes diagnosis.
Eligibility for Wegovy and Ozempic Insurance Coverage
Insurers often require proof that the medication is medically necessary. This might involve documentation of your BMI, weight-related health conditions, and previous attempts at weight loss.
Your plan may require prior authorization, meaning the prescribing doctor must obtain approval from the insurance company before your carrier will pay for the medication.
Additionally, your plan may require that you have tried other less expensive ways to reduce weight, such as diet, exercise, and more traditional weight loss drugs. If you’re considering embarking on a weight loss journey in the near future, and you want to maximize your health insurance benefits, it’s best to start your weight loss efforts now, and document them.
That way, if these more traditional methods prove to be ineffective, your “prerequisites” will be out of the way that much sooner!
Learn More: Why Losing Even a Little Weight Can Help A Lot
Savings and Support Programs
The manufacturer of Ozempic, Novo-Nordisk, offers a savings program for those with commercial insurance and a valid prescription.
There’s a similar savings program for those with a prescription for Wegovy.
Note: You are not eligible if you are enrolled in any federal or state health care program with prescription drug coverage, such as Medicaid, Medicare, Medigap, VA, DOD, TRICARE, or any similar federal or state health care program.
Wegovy and Ozempic When Insurance Isn’t an Option
If you’ve tried diet and exercise and the older generic weight loss medications with unsatisfactory results, and your doctor suggests these newer, more expensive medications, your insurance may not cover them – especially if you don’t have diabetes, which is the primary on-label use for these drugs.
Or perhaps you don’t have insurance at all. In this case, you will have to pay out of pocket. But you don’t have to pay the full retail sticker price for these meds. Try a pharmacy discount app such as GoodRx, which may allow you to save up to 25% off of brand name drugs like Ozembic, and up to 80% off the retail price of many generic drugs.
Additionally, if you’re an HSA for America client, you have access to the HSA AdvantageRx discount card through RxCare, which qualifies you for steep discounts on many other popular prescription drugs, lab services, imaging, and more.
To download your card and start saving right away, click here.
Learn More: The Best Prescription Discount Cards for 2024
Bariatric Surgery
Bariatric surgery is extreme, but it is an effective intervention for severely obese individuals.
It’s also covered under ACA-qualified health insurance plans. Procedures such as gastric bypass, sleeve gastrectomy, and adjustable gastric banding are typically covered if you meet specific criteria.
While specifics may vary by carrier, you can expect eligibility criteria to be similar to the following:
- A BMI of 40 or higher
- A BMI of 35 or higher with obesity-related health conditions
- Documentation of previous weight loss attempts under medical supervision
Insurance plans usually require a thorough evaluation process, including nutritional and psychological counseling, to ensure you are a suitable candidate for surgery.
You may also need to demonstrate the ability to lose weight on your own by reducing caloric intake and exercise, along with pharmacological support, before your doctor will be willing to perform the surgery.
Non-Invasive Weight Loss Treatments
Less extreme interventions, such as gastric balloons and endoscopic procedures, are gaining popularity as alternatives to traditional bariatric surgery.
The gastric balloon is a saline-filled balloon inserted into the stomach in a much less invasive procedure than bariatric surgery or liposuction. The presence of the balloon helps you feel full faster, and reduce caloric intake, helping you lose weight.
The balloon is removed after about six months, but you’ll still continue to participate in a physician-supervised weight loss program.
However, despite its promise, insurance carriers aren’t covering gastric balloon treatment as of yet. Patients undergoing this procedure face out-of-pocket costs of $7,000 to $10,000.
Many patients choose to finance the cost with a third-party finance company, which is an option for many medical procedures. Your doctor may have an arrangement with a finance company, or you can search for medical services consumer finance companies on your own.
Nutritional Counseling
Nutritional counseling is an essential component of any weight loss program. ACA-qualified health insurance plans often cover these services, especially if you have a diagnosis of obesity or related health conditions. Coverage typically includes a set number of visits per year with a registered dietitian or nutritionist.
Psychological Counseling and Behavioral Therapy
Behavioral therapy and psychological counseling are crucial for addressing the underlying factors contributing to obesity.
Many ACA-qualified plans cover these services as part of a comprehensive weight loss program. This coverage may include individual counseling sessions, group therapy, and behavioral modification programs.
Exercise Programs and Fitness Club Memberships
While most health insurance plans do not directly cover gym memberships or fitness club fees, some insurers offer wellness programs that provide discounts or reimbursements for these expenses.
Additionally, certain plans may cover supervised exercise programs, particularly if they are part of a medically supervised weight loss program.
Using HSA Dollars for Weight Loss
Health Savings Accounts (HSAs) offer a tax-advantaged way to save for medical expenses, including some weight loss-related costs. Here’s what you need to know about using HSA dollars for weight loss:
Eligible Expenses
HSA funds can be used for the following weight loss-related expenses:
- Health insurance deductibles
- Health insurance copays
- Health insurance co-insurance (e.g., your 20% responsibility in an ‘80-20’ health insurance plan
- Alternative therapies
- Prescription weight loss medication costs
- Physician’s consulting fees
- Counseling and therapy
- Dietician fees
- Nutritional supplements (only if a doctor recommends as treatment for a specific medical condition)
- Capital expenses (for example, for modifying a home to accommodate your condition)
- Chiropractic care
- Blood glucose test kits
- Mental healthcare related to your obesity
- Weight reduction group membership fees (if a doctor determines your weight loss is medically necessary for treatment of a specific diagnosed condition).
- Specialist fees and consultation costs
- Bariatric surgery costs, including consultations, surgeon’s fees, anesthesiologist fees, hospital fees, and follow-up care costs.
- Travel/transportation costs to receive medical care
- Lodging for yourself and one other person to assist you
Ineligible Expenses
Certain weight loss-related costs are generally not eligible for HSA reimbursement, including:
- Gym memberships or fitness club fees (unless part of a prescribed medical program)
- Over-the-counter weight loss supplements
- Non-prescription diet programs
Maximizing The Value of Your HSA
Here’s how make the most of your HSA for weight loss:
- Obtain a letter of medical necessity from your doctor for eligible expenses. This letter can help you make the case that your expense qualifies as an HSA-eligible expense if you get audited by the IRS and they challenge your claim later on.
- If you want to take supplements or vitamins, get a letter of medical necessity from your doctor for those, too. You can use your HSA to pay for these items, as long as they are medically necessary to treat a specific diagnosis. You can’t, however, use your HSA if you are taking them for general wellness purposes without a related clinical diagnosis.
- Keep detailed records and receipts of all related expenses.
- Read our blog post on what constitutes a medically necessary expense.
Learn More: Using Your HSA to Pay for Supplements
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Health Insurance for Weight Loss Conclusion
While today’s ACA-qualified health insurance plans all cover the very basics when it comes to weight loss, plans can vary significantly in coverage of higher-cost treatments, such as Wegovy, Ozempic, and bariatric surgery.
Some carriers will have higher copays on these higher-tier medications, or more stringent eligibility and pre-authorization requirements than others.
That’s why it’s vital to work with a qualified, experienced health insurance professional who can help you look deep into your insurance options, review plan formularies, and specific criteria for surgical weight loss interventions.
Our expert Personal Benefits Managers can help with all this, and more – no charge. Just make an appointment, and we’ll walk you through the process from there. We’ll go over all your options, and help you work out a strategy and get you enrolled in a plan you can afford.
It’s easy, and stress free.
For Further Reading: How To Use HSAs and Tax Deductions To Save Money on Weight Loss Programs | New 2024 HSA Contribution Limits Let You Save Even More on Taxes | The Tax Treatment of Health Savings Accounts
Hi! I’m Misty Berryman, and I’m one of your Personal Benefits Managers. I like working with HSA for America because we’re creating solutions to healthcare problems. Our focus on money-saving alternatives like HSA plans and health sharing programs, and the variety of health share programs we offer, are what set us apart. Read more about me on my Bio page.
