Medicare Recommends Coverage of Seniors for Intense Obesity Counseling

Assistance to Combat ObesityThe U.S. Centers for Medicare and Medicaid Services (CMS) issued a proposed Decision Memorandum on August 31, 2011, recommending that seniors who have Medicare Part A or Part B should be covered for an obesity screening, dietary assessment, and, if indicated, intensive behavioral counseling in diet and exercise and behavioral therapy to promote sustained weight loss.

These services would need to be provided by a “primary care physician” or “primary care practitioner” (nurse practitioner, clinical nurse specialist, or physician assistant) in a “primary care setting.”

The proposed Decision Memorandum with CMS’ recommendations is posted on the CMS website.

CMS developed these recommendations, taking into consideration comments received from the public during a 30 day comment period on a prior draft.

CMS has asked for additional public comments on its present recommendations. “We are requesting public comments on this proposed determination pursuant to section 1862(l) of the Social Security Act,” the CMS memorandum states. “After considering the public comments, we will make a final determination and issue a final decision memorandum,” CMS states.

The public is invited to submit questions or comments online.

The CMS Recommendations

“The evidence is adequate to conclude that intensive behavioral therapy for obesity, defined as a body mass index (BMI) ≥ 30 kg/m2, is reasonable and necessary for the prevention or early detection of illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B and is recommended with a grade of A or B by the U.S. Preventive Services Task Force (USPSTF),” CMS wrote in its August 31 Decision Memorandum.

Intense Behavioral Therapy. CMS indicated that “Intensive behavioral therapy for obesity” would consist of the following:

  1. Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed in kg/m2);
  2. Dietary (nutritional) assessment; and
  3. Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise.

CMS recommended that to qualify for Medicare coverage, the “intensive behavioral intervention for obesity” should be consistent with a “5-A framework” developed by the U.S. Preventive Services Task Force (USPSTF):

  1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
  2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
  3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
  4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
  5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

Frequency of Counseling. CMS indicated that “For Medicare beneficiaries with obesity, who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting, CMS proposes to cover:”

* One face to face visit every week for the first month;
* One face to face visit every other week for months 2-6;
* One face to face visit every month for months 7-12.

Re-evaluation at 6 Months. “At the six month visit, a reassessment of obesity and a determination of the amount of weight loss should be performed,” CMS stated. Under CMS’ recommendations, the Medicare beneficiary would need to have lost at least 3kg (6.6 pounds) of weight during the first 6 months of intensive therapy in order to be eligible for another 6 months of face to face visits once a month. This weight loss would need to be documented by the person’s primary care physician.

In Primary Care Setting Only. The CMS proposed decision memorandum indicates that the obesity services would need to be provided by a primary care physician or primary care practitioner (such as a nurse practitioner, clinical nurse specialist, or physician assistant). The services would also need to be delivered in a “primary care setting,” such as a doctors office or clinic, not in a hospital emergency department, hospital, or skilled nursing or rehab facility, CMS recommended.

Request for Further Public Comments

CMS indicates, “We are requesting public comments on this proposed determination pursuant to section 1862(l) of the Social Security Act. After considering the public comments, we will make a final determination and issue a final decision memorandum.”

CMS provides a link with its memorandum, where it invites the public to submit comments or questions online.

More Information

See the full CMS proposed Decision Memorandum at the CMS website.

See previous reports by HelpingYouCare™ on:

Under Affordable Care Act, Preventive Services Now Free to Medicare Beneficiaries

How Do People Lose Weight & What Can Be Done About the Obesity Epidemic?

Smart Diet Tips & Tools

Medicare Adds New Online Tools to Help Health Care Consumers

Affordable Care Act Will Save $120 Billion for Medicare over 5 Years

Affordable Care Act Has Saved Medicare Beneficiaries $260 Million on Prescription Drugs in 5 Months

See also the HelpingYouCare™ resource pages on Wellness/ Healthy Living for Seniors & Caregivers, including:

Diet & Nutrition: Physical Wellness;

Exercise: Physical Wellness;

As well as our other wellness topics.

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Copyright © 2011 Care-Help LLC, publisher of HelpingYouCare™.

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