wa-law.org > bill > 2025-26 > SB 5353 > Original Bill

SB 5353 - Diabetes and obesity

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Section 1

  1. For health plans issued or renewed on or after January 1, 2026, a health carrier shall include coverage for the diagnosis and treatment of the chronic disease of obesity including, but not limited to:

    1. Intensive health behavioral and lifestyle treatment;

    2. Metabolic and bariatric surgery; and

    3. Food and drug administration-approved obesity medication.

  2. Coverage criteria for food and drug administration-approved obesity medications may not be more restrictive than the food and drug administration-approved indications for those treatments.

  3. Coverage under this section may not be different or separate from coverage for any other illness, condition, or disorder for purposes of determining deductibles, copayment, and coinsurance factors, and benefit year maximums for deductibles, copayment, and coinsurance factors.

  4. This section does not prohibit a health carrier from applying utilization management to determine the medical necessity for treatment of the chronic disease of obesity under this section if appropriateness and medical necessity determinations are made in the same manner as those determinations are made for the treatment of any other illness, condition, or disorder covered by a contract.

  5. Intensive health behavior and lifestyle treatment may include interventions certified by or recognized by the centers for disease control and prevention or recommended by current clinical standards of care.

  6. For purposes of this section:

    1. "Intensive health behavior and lifestyle treatment" means an evidence-based, intensive, multicomponent behavioral or lifestyle modification intervention that supports healthy weight management and is delivered in-person or through telemedicine as defined in RCW 48.43.735.

    2. "Food and drug administration-approved obesity medication" means any medication approved by the United States food and drug administration with an indication for chronic weight management in patients with an obesity diagnosis.

    3. "Metabolic and bariatric surgery" means any surgical intervention included in the most current American society for metabolic and bariatric surgery and international federation for the surgery of obesity and metabolic disorders guidelines on indications for metabolic and bariatric surgery.

Section 2

Each health plan that provides medical insurance offered under this chapter, including plans created by insuring entities, plans not subject to the provisions of Title 48 RCW, and plans created under RCW 41.05.140, are subject to the provisions of RCW 48.43.500, 70.02.045, 48.43.505 through 48.43.535, 48.43.537, 48.43.545, 48.43.550, 70.02.110, 70.02.900, 48.43.190, 48.43.083, 48.43.0128, 48.43.780, 48.43.435, 48.43.815, 48.200.020 through 48.200.280, 48.200.300 through 48.200.320, 48.43.440, section 1 of this act, and chapter 48.49 RCW.

Section 3

  1. By November 1, 2025, the authority shall apply for authorization from the federal centers for medicare and medicaid services to receive matching federal funds for providing the services covered under this section.

  2. Upon federal authorization, the authority and all managed care organizations shall provide coverage to provide treatment of the chronic disease of obesity including, but not limited to:

    1. Intensive health behavioral and lifestyle treatment;

    2. Metabolic and bariatric surgery; and

    3. Food and drug administration-approved obesity medication.

  3. Coverage criteria for food and drug administration-approved obesity medications may not be more restrictive than the food and drug administration-approved indications for those treatments.

  4. This section does not prohibit the authority and managed care organizations from applying utilization management to determine the medical necessity for treatment of the chronic disease of obesity under this section if appropriateness and medical necessity determinations are made in the same manner as those determinations are made for the treatment of any other illness, condition, or disorder covered by a contract.

  5. Intensive health behavior and lifestyle treatment may include interventions certified by or recognized by the centers for disease control and prevention or recommended by current clinical standards of care.

  6. For purposes of this section:

    1. "Intensive health behavior and lifestyle treatment" means an evidence-based, intensive, multicomponent behavioral or lifestyle modification intervention that supports healthy weight management and is delivered in-person or through telemedicine as defined in RCW 74.09.325.

    2. "Food and drug administration-approved obesity medication" means any medication approved by the United States food and drug administration with an indication for chronic weight management in patients with an obesity diagnosis.

    3. "Metabolic and bariatric surgery" means any surgical intervention included in the most current American society for metabolic and bariatric surgery and international federation for the surgery of obesity and metabolic disorders guidelines on indications for metabolic and bariatric surgery.

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