That means a Virginia consumer considering gastric bypass or bariatric surgery will have to pay up to $1,500 a month more for plans that cover the procedure.
Consumers in Maryland, by contrast, could buy any policy in the marketplace — and for dramatically less than the Virginia rider plans — and be covered for bariatric surgery because that state requires all plans to pay for it. In the District, insurers are not required to offer the surgical treatment, either as a rider or a standard benefit. The procedure can cost $15,000 to $25,000.
The difference between the approaches in Virginia and Maryland reflects some of the reasons for the broad variation in prices and benefits among policies offered under the federal health law.
Debates about how much to require insurers to cover and where to draw the line have long roiled state capitals as lawmakers are lobbied to mandate coverage of specific treatments or specialists. State laws vary, with some having fewer than 20 mandates and others, like Maryland, having more than double that number.
Proponents see mandated benefit coverage as a way to protect consumers, while opponents say they drive up the cost of premiums for everyone, sometimes for questionable treatments pushed by special interests. Recent fights have included whether to require insurers to cover treatment for autism or in vitro fertilization.
“This reflects a classic tension between trying to keep costs low and trying to do the right thing,” said Dan Mendelson of consulting firm Avalere Health. “Legislatures have to make a call on whether something is a necessary medical intervention or just something nice to have.”
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 individuals are governed by state rules, so coverage varies. The procedure, which makes the stomach smaller, is one of a number of treatments offered to patients who are severely overweight. About 200,000 such surgeries are performed annually.
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 plan selected by Virginia officials as the standard for what must be sold through the new marketplaces.