Obesity and Weight Loss Coverage

How Important Is Weight Control For Older Adults?

People used to think if you were older it was better for you to be overweight. Today we know that isn't true.Most importantly, Medicare agrees that being overweight is a concern for seniors. In fact, in 2004 Medicare expanded their coverage for weight loss interventions. They will now cover proven weight loss programs, including weight loss surgery.

How Does Obesity Affect Seniors’ Health?

According to health experts, an estimated 20% of U.S. adults over 65 are obese and another 40% are overweight. The extra pounds substantially increase the risk for diabetes, hypertension, heart disease and other illnesses. In addition, studies have consistently shown that even small reductions in weight and increases in physical activity can improve seniors’ health and help them look and feel better.

Why Is It Harder for Seniors to Lose Weight?

Losing weight is a challenge for anyone. For seniors, however, the challenges are much more complicated. For example, a large number of people over 65 are dealing with multiple health problems. They may have high blood pressure, diabetes, heart disease, kidney problems or all of the above. In addition, seniors have many more barriers to overcome than their younger counterparts.

Physical barriers can include:

Joint pain that makes it difficult to move.
Balance problems that increase the risk of falling.
Vision problems that make it harder to move in unfamiliar locations
Concerns about safety when exercising outdoors
Lack of mobility

Barriers to dietary change:

Reduced ability to taste, which tends to lure seniors toward foods higher in calories because of their sweet and/or salty taste
Long-term eating habits that are harder to change
Limited income: reduced ability to pay for expensive diet foods

Other barriers:

Many take medications that increase weight or make it impossible to lose it
Older adults tend to lose weight more slowly than younger adults
Multiple health issues that limit the types of foods they can eat and complicate dietary and exercise recommendations

The good new is that safe and successful dieting in the older population is possible. It requires health professionals who understand the challenges of seniors and know how to overcome them. The effort it takes is well worth it, since weight loss and a moderate exercise programs have been shown to help improve the health and well-being of seniors.

Does Medicare Cover Weight Loss Programs?

Yes, under certain conditions Medicare will cover weight loss programs.

How Do I Qualify for Coverage Under Medicare?

Medicare will cover certain weight loss services and programs:

When weight loss is a necessary part of treatment for diseases such as hypothyroidism, Cushing’s disease, hypothalamic lesions, cardiovascular diseases, respiratory diseases, diabetes, and hypertension (and others)
Before surgery, when the weight loss is necessary to reduce possible complications posed by obesity

To qualify, you must be under the care of a doctor. The doctor must write an order (prescription) for the services and the need for the services must be documented in your medical records.

If you get your coverage from a Medicare Advantage Plan, call your plan and ask about qualifying for weight loss services. Your plan may offer additional services.

What Does Medicare Cover?

Medicare will cover the following:

An initial assessment of your eating and activity habits
Counseling on diet and physical activity
Education on how to improve your diet and changes that will help you lose weight and improve your health
Follow-up visits to monitor your diet and weight loss progress

Important things to know:

Medicare will cover up to three hours of individual counseling services the first year, and two hours each year after that.
If your condition or treatment needs changing, you may be able to receive more services. Your doctor must write an order (prescription) for the additional service each year they are needed.
You must receive the services from a qualified health professional who is Medicare-certified.

If you get your care from a Medicare Advantage or MediGap plan, your plan may offer additional coverage.

What Will It Cost Me?

Your out-of pocket cost will depend on they type of Medicare plan you have. For example:

Medicare covers 80% of the approved amount for the service; you are responsible for the remaining amount.
If you have a MediGap Supplemental Plan, call to find out what is covered by the plan. With a MediGap plans you will pay little or nothing.
If you have a Medicare Advantage Plan, call the plan for information on coverage. Remember the plan must cover at least what Medicare does; many cover more.

How Do I Find a Provider?

If you are interested in losing weight, you should go to your doctor and ask for recommendations. The doctor will be responsible for monitoring your program and documenting your progress, and will likely have an ongoing working relationship with local providers or have them on staff.

If you get your coverage from a Medicare Advantage or MediGap plan, you may have to use the providers they have on contract.

Getting Care Directly through Medicare

Ask your doctor, friends and family for recommendations and do your homework. Before you choose a provider, ask:

If they are participating providers
If they accept assignment
Them to write down what the charges are and how much you will have to pay

If your supplier does not accept assignment:

They can charge more than the Medicare-approved amount
They can ask you to pay the entire cost of your services when you receive them
You may have to bill Medicare on your own and wait for reimbursement. It can take several weeks.

Other Important Things to Know

If the supplier is not enrolled in Medicare, Medicare will not pay the claim.
You must have paid your annual deductible before Medicare will begin to pay its share.
A signed and dated order (prescription) must be on file with the provider.

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