The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule that would allow Medicare Part D prescription drug plans to cover anti-obesity medications. Historically, drugs used for weight loss have been excluded from the definition of a covered Part D drug, regardless of their use for the treatment of individuals with obesity, and have been an optional drug benefit for Medicaid programs.
According to CMS, increases in the prevalence of obesity in the United States and changes in the prevailing medical consensus towards recognizing obesity as a disease have compelled the agency to reevaluate coverage of anti-obesity medications.
Key Highlights
CMS is proposing to reinterpret the law to no longer exclude anti-obesity medications for the treatment of obesity from coverage under Medicare Part D and to require Medicaid programs to cover these medications when used to treat obesity. Accordingly, under this interpretation:
- Anti-obesity medications could not be excluded from coverage when used for weight loss or chronic weight management for the treatment of obesity; and
Anti-obesity medications that are used for weight loss in individuals who do not have obesity or another condition that is a medically accepted indication remain excluded from the definition of a covered Part D drug and would remain an optional benefit for Medicaid programs.
While the proposal is not limited to particular anti-obesity drugs or drug classes, CMS acknowledged that newer medications in the glucagon-like peptide-1 (GLP- 1) and glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor agonist classes have emerged as preferred therapies over older medications and are therefore likely to be the driver of overall costs related to the proposal.
IMPACT ON PRIVATE PLANS
While there is no immediate impact on private health plan coverage, CMS acknowledged that the proposal could prompt changes in private health plan coverage outside of Medicare and Medicaid (for example, by impacting premiums for these plans).
CMS has requested comments on the potential impact of the proposal on the private employer insurance market.
Next Steps
Comments on the proposal must be received by Jan. 27, 2025, and the coverage requirements would generally apply to Medicare plan enrollees signing up for 2026 coverage. However, it is important to keep in mind that the proposal is part of the Biden-Harris Administration’s efforts to revise and improve Medicare. The proposal could be significantly altered or withdrawn altogether under the incoming Trump administration, though this remains to be seen.
Plan administrators of private employer-sponsored health coverage should nevertheless stay apprised of the latest developments regarding the proposal since it has the potential to impact premiums, and any potential change enabling Medicare plan enrollees to access these medications might eventually compel private plans to broaden their coverage as well.
Provided by Ollis/Akers/Arney Insurance & Business Advisors
This Legal Update is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. ©2024 Zywave, Inc. All rights reserved.
