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    Affordable Care Act: State Rules Can Boost Costs


    Obesity is considered a medical condition, but surgical interventions are not universally covered. While many large, employer-sponsored insurance plans, along with Medicare, cover the surgeries, policies sold to small businesses and individual customers are governed by state rules, so coverage is more variable. The procedure, which essentially makes the stomach smaller, is one of a number of treatments offered to patients who are severely overweight. Nationally, about 200,000 such surgeries are performed annually, usually costing between $15,000 to $25,000.

    Virginia is among a handful of states, along with Georgia and Indiana, where laws that predate the health law require that bariatric treatment must be offered as an option for consumers, but not necessarily included in every plan sold to small businesses and people who buy their own coverage. But bariatric surgery is not a required benefit in the plans selected by Virginia or Georgia as the standard for what must be sold through the new marketplaces.

    Virginia’s pricing “is a barrier for people getting coverage,” Joe Nadglowski, president and CEO of the Florida-based advocacy group Obesity Action Coalition. “Some of the decisions that insurers make around bariatric surgery seem not to be based on economics or health, but are often more based on stigma and bias.”

    One mid-level policy from insurer Optima that covers the treatment, for example, is priced at $1,858 a month for a 27-year-old, but the same plan from the same insurer is $285 without the rider. Similar plans by other insurers, including Aetna, Coventry One and Innovation Health, range from $1,100 a month to $1,500, well above what the insurers charge for plans without the rider.

    A spokesman for Blue Cross Blue Shield of Georgia said that insurer is not offering riders that cover the surgery in its policies sold in the new marketplaces.

    Under the health law, benefit packages must include 10 broad categories of care, including hospital coverage, maternity care, prescription drugs and mental health services. But states were given some leeway in choosing what else to include in that list. Along with Virginia, 27 other states chose benchmark policies that do not cover the surgical treatment for obesity, according to an analysis by the obesity coalition.

    Fri, Oct 11 2013

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