Question: We understand that our company's major medical plan has to cover screenings for obesity in adults. But, beyond that, can our plan have a general exclusion for weight-management services, such as obesity counseling and behavioral management activities, for adult obesity?
Answer: Most group health plans cannot contain a general exclusion for weight-management services for adult obesity. The Affordable Care Act (ACA) requires nongrandfathered, nonexcepted group health plans to provide coverage for specified preventive services without cost-sharing when those services are delivered by in-network providers. And the U.S. Department of Health and Human Services website lists the preventive services that must be covered, which are based on recommendations and guidelines from a number of organizations — including the U.S. Preventive Services Task Force (USPSTF).
Recommendations in Play
As you note, coverage of screenings for obesity in adults is required. It's currently listed by the USPSTF as a recommended preventive service. In addition to recommending such screenings, however, the USPSTF suggests specific behavioral interventions for weight management for adult patients based on body mass index. These include:
- Group and individual sessions
- Weight-loss goal setting
- Strategies for how to maintain lifestyle changes
Plans may use reasonable medical management techniques to determine the frequency, method, treatment or setting for recommended preventive services (to the extent not specified). But they're not permitted to impose general exclusions. Thus, your company's major medical plan cannot include a general exclusion that would encompass weight-management services for adult obesity that are specified in USPSTF recommendations.
Other Requirements
Also keep in mind that small group market plans, which are subject to the ACA's essential health benefits requirement, may have to cover certain weight-management services as required preventive or wellness services. Furthermore, exclusions of counseling or behavioral management services may fail to comply with other laws such as the mental health parity requirements and the Americans with Disabilities Act (to the extent they make disability-based distinctions). Work closely with your benefits advisors to identify allowable exclusions.
If you have questions about exclusions in group health plans, please contact Ron Present, Partner and Health Care Industry Group Leader, at rpresent@bswllc.com or 314.983.1358.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
