Posted 11/17/2015

Prepared by Christopher Gallagher, ASMBS Washington Representative

U.S. Department of Labor (DOL) Issues FAQ on Weight Loss Program Exclusions

On Friday, Oct. 23, the United States Department of Labor (DOL) issued a FAQ, which advises against coverage exclusions for weight management as part of the implementation of the Affordable Care Act. The effort is a win for obesity treatment coverage, resulting from efforts by the Obesity Care Continuum and our partners.

The question related to weight management is as follows:

Q6: My non-grandfathered group health plan or coverage contains a general exclusion for weight management services for adult obesity. Is this permissible?

No. Consistent with PHS Act section 2713, its implementing regulations, and current USPSTF recommendations, non-grandfathered plans and issuers must cover, without cost sharing, screening for obesity in adults. In addition to such screening, the USPSTF currently recommends, for adult patients with a body mass index (BMI) of 30 kg/m2 or higher, intensive, multicomponent behavioral interventions for weight management. The recommendation specifies that intensive, multicomponent behavioral interventions include, for example, the following:
• Group and individual sessions of high intensity (12 to 26 sessions in a year),
• Behavioral management activities, such as weight-loss goals,
• Improving diet or nutrition and increasing physical activity,
• Addressing barriers to change,
• Self-monitoring, and
• Strategizing how to maintain lifestyle changes.

While plans and issuers may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive service, to the extent not specified in the recommendation or guideline regarding that preventive service, plans are not permitted to impose general exclusions that would encompass recommended preventive services.

Additionally, with respect to individual and small group market issuers subject to the essential health benefits (EHB) requirements under section 1302(b) of the Affordable Care Act and section 2707(a) of the PHS Act, to the extent the applicable EHB-benchmark plan does not include coverage of the required preventive services, including obesity screening and counseling, the issuer must nonetheless provide coverage for such preventive services consistent with PHS Act section 2713 and its implementing regulations, and with the regulation implementing the EHB requirements at 45 CFR 156.115(a)(4).