HOUSE BILL 675

Unofficial Copy 2001 Regular Session

C3 1lr0386

SB 496/00 - FIN CF 1lr0385

____________________________________________________________________________________

By: Delegate Goldwater

Introduced and read first time: February 7, 2001

Assigned to: Economic Matters

_____________________________________________________________________________________

A BILL ENTITLED

1 AN ACT concerning

2 Health Insurance - Treatment of Morbid Obesity

3 FOR the purpose of requiring certain insurers, nonprofit health service plans, health

4 maintenance organizations, managed care organizations, and carriers to provide

5 coverage for the expenses incurred by certain obese patients for surgical

6 treatment under certain circumstances; authorizing certain benefits to be

7 provided through a managed care system; defining certain terms; providing for

8 the application of this Act; and generally relating to coverage of expenses for

9 treatment of morbid obesity under health insurance.

10 BY adding to

11 Article - Insurance

12 Section 15-837

13 Annotated Code of Maryland

14 (1997 Volume and 2000 Supplement)

15 BY adding to

16 Article - Health - General

17 Section 19-706(rr)

18 Annotated Code of Maryland

19 (2000 Replacement Volume)

20 Preamble

21 WHEREAS, Obesity is a significant health problem affecting hundreds of

22 thousands of Maryland residents; and

23 WHEREAS, Severe or morbid obesity increases the mortality rate more than

24 threefold, causes physical and emotional disability, is often associated with comorbid

25 conditions compounding its adverse impact on longevity and quality of life, and is

26 amenable to established surgical treatment; and

27 WHEREAS, Like other chronic diseases, obesity is caused or aggravated by

28 many factors including genetics, behavior, metabolism, and environment, certain

2 HOUSE BILL 675

1 therapeutic interventions can alter its course and severity, and therefore, obesity

2 should be treated for purposes of insurance like other medical conditions; and

3 WHEREAS, Health insurance policies commonly exclude coverage for the

4 treatment of obesity, even when severe or morbid and complicated by comorbid

5 conditions; now, therefore,

6 SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF

7 MARYLAND, That the Laws of Maryland read as follows:

8 Article - Insurance

9 15-837.

10 (A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS

11 INDICATED.

12 (2) "BODY MASS INDEX" MEANS A PRACTICAL MARKER THAT IS USED TO

13 ASSESS THE DEGREE OF OBESITY AND IS CALCULATED BY DIVIDING THE WEIGHT IN

14 KILOGRAMS BY THE HEIGHT IN METERS SQUARED.

15 (3) "MANAGED CARE SYSTEM" MEANS A METHOD THAT AN INSURER,

16 NONPROFIT HEALTH SERVICE PLAN, OR HEALTH MAINTENANCE ORGANIZATION

17 USES TO REVIEW AND PREAUTHORIZE A TREATMENT PLAN THAT A HEALTH CARE

18 PRACTITIONER DEVELOPS FOR A COVERED PERSON USING A VARIETY OF COST

19 CONTAINMENT METHODS TO CONTROL UTILIZATION, QUALITY, AND CLAIMS.

20 (4) "MORBID OBESITY" MEANS A BODY MASS INDEX GREATER THAN 40

21 KILOGRAMS PER METER SQUARED.

22 (B) THIS SECTION APPLIES TO:

23 (1) INSURERS AND NONPROFIT HEALTH SERVICE PLANS THAT PROVIDE

24 HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS ON AN

25 EXPENSE-INCURRED BASIS UNDER HEALTH INSURANCE POLICIES OR CONTRACTS

26 THAT ARE ISSUED OR DELIVERED IN THE STATE;

27 (2) HEALTH MAINTENANCE ORGANIZATIONS THAT PROVIDE HOSPITAL,

28 MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS UNDER CONTRACTS

29 THAT ARE ISSUED OR DELIVERED IN THE STATE;

30 (3) MANAGED CARE ORGANIZATIONS, AS DEFINED IN § 15-101 OF THE

31 HEALTH - GENERAL ARTICLE; AND

32 (4) CARRIERS THAT OFFER HEALTH BENEFIT PLANS UNDER TITLE 15,

33 SUBTITLE 12 OF THE INSURANCE ARTICLE.

34 (C) SUBJECT TO SUBSECTION (E) OF THIS SECTION, AN ENTITY SUBJECT TO

35 THIS SECTION SHALL PROVIDE COVERAGE FOR THE EXPENSES INCURRED BY A

36 PATIENT WITH MORBID OBESITY FOR ESTABLISHED SURGICAL TREATMENT IF:

3 HOUSE BILL 675

1 (1) ALL NONSURGICAL MEDICAL THERAPIES, AS DETERMINED BY THE

2 PHYSICIAN, HAVE FAILED; AND

3 (2) THE BODY MASS INDEX OF THE PATIENT EXCEEDS:

4 (I) 40 KILOGRAMS PER METER SQUARED; OR

5 (II) 35 KILOGRAMS PER METER SQUARED IN THE PRESENCE OF

6 HYPERTENSION, DIABETES, HIGH LDL CHOLESTEROL, LOW HDL CHOLESTEROL,

7 HYPERTRIGLYCERIDEMIA, SLEEP-APNEA SYNDROME, OSTEOARTHRITIS, OR OTHER

8 MEDICAL CONDITIONS CONSIDERED BY A PHYSICIAN POTENTIALLY REMEDIABLE BY

9 SIGNIFICANT WEIGHT REDUCTION.

10 (D) AN ENTITY SUBJECT TO THIS SECTION SHALL PROVIDE THE BENEFITS

11 REQUIRED UNDER THIS SECTION TO THE SAME EXTENT AS FOR ANY OTHER

12 MEDICAL CONDITION UNDER THE ENROLLEE'S OR INSURED'S CONTRACT OR POLICY

13 WITH THE ENTITY.

14 (E) AN ENTITY SUBJECT TO THIS SECTION MAY PROVIDE THE BENEFITS

15 REQUIRED UNDER THIS SECTION THROUGH A MANAGED CARE SYSTEM.

16 Article - Health - General

17 19-706.

18 (RR) THE PROVISIONS OF § 15-837 OF THE INSURANCE ARTICLE APPLY TO

19 HEALTH MAINTENANCE ORGANIZATIONS.

20 SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all

21 policies, contracts, and health benefit plans issued, delivered, or renewed in the State

22 on or after October 1, 2001.

23 SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect

24 October 1, 2001.

Additional Information

House Bill 675 sponsored by Delegate Goldwater requires insurers, HMO, Managed Care Organizations to provide coverage for surgical treatment of morbid obesity as recognised by NIH, effective 10/01/01

This law requires health insurers to provide coverage of morbid obesity surgery to the same extendt as other medically necessary surgical procedures. The patient must adhere to NIH guidelines, such as be classified as morbidly obese, being 100 lbs over weight, and have a BMI of at least 35 and have other comorbidities or coexisting medical conditions such as hypertention, sleep apnea, diabetes and cardiopulmonary conditions. House Bill 675 will apply to all policies, contracts and health plans issued, delivered or renewed in the State of Maryland on or after October 1, 2001.