CODE OF VIRGINIA

COVERAGE FOR THE TREATMENT OF MORBID OBESITY (§ 38.2-3418.13)

A. Notwithstanding the provisions of § 38.2-3419, in the large group market,
each insurer proposing to issue accident and sickness insurance policies
providing hospital, medical and surgical, or major medical coverage on an
expense-incurred basis; each corporation providing accident and sickness
subscription contracts; and each health maintenance organization providing a
health care plan for health care services shall offer and make available
coverage under any such policy, contract or plan for the treatment of morbid
obesity through gastric bypass surgery or such other methods as may be
recognized by the National Institutes of Health as effective for the long-term
reversal of morbid obesity.

B. The reimbursement for the treatment of morbid obesity shall be determined
according to the same formula by which charges are developed for other medical
and surgical procedures. Such coverage shall have durational limits, dollar
limits, deductibles, copayments and coinsurance factors that are no less
favorable than for physical illness generally.  Standards and criteria,
including those related to diet, used by insurers to approve or restrict access
to surgery for morbid obesity shall be based upon current clinical guidelines
recognized by the National Institutes of Health.

C. For purposes of this section, “morbid obesity” means (i) a weight
that is at least 100 pounds over or twice the ideal weight for frame, age,
height, and gender as specified in the 1983 Metropolitan Life Insurance tables,
(ii) a body mass index (BMI) equal to or greater than 35 kilograms per meter
squared with comorbidity or coexisting medical conditions such as hypertension,
cardiopulmonary conditions, sleep apnea, or diabetes, or (iii) a BMI of 40
kilograms per meter squared without such comorbidity. As used herein, BMI equals
weight in kilograms divided by height in meters squared.

D. The provisions of this section shall not apply to short-term travel,
accident-only, limited or specified disease policies or contracts designed for
issuance to persons eligible for coverage under Title XVIII of the Social
Security Act, known as Medicare, or any other similar coverage under state or
governmental plans or to short-term nonrenewable policies of not more than six
months’ duration; health care plans, contracts, or policies issued in the
individual or small group market; or a qualified health plan when the plan is
offered in the Commonwealth by a health carrier through a health benefit
exchange established under § 1311 of the federal Patient Protection and
Affordable Care Act (P.L. 111-148).

HISTORY: 2000, c. 465; 2003, c. 462; 2014, c. 814.