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Colorado first state to require gender-affirming care as essential health benefit on certain plans

Officials say individual and small-group markets cover about one-quarter of Coloradans
colorado state capitol
Posted at 12:44 PM, Oct 12, 2021
and last updated 2021-10-12 19:57:12-04

DENVER – State and federal officials announced Tuesday that more gender-affirming care and mental and behavioral health care would be covered as essential health benefits on Colorado’s individual and small-group health insurance plans starting in 2023.

The Centers for Medicare & Medicaid Services (CMS) announced the approval of Colorado’s request to expand its essential health benefits to include more gender-affirming care for LGBTQ+ people, making the state the first in the nation to have such coverage approved, CMS Administrator Chiquita Brooks-LaSure said at a news conference alongside Gov. Jared Polis, Lt. Gov. Dianne Primavera, Insurance Commissioner Mike Conway and Sen. Brittany Pettersen, D-Lakewood, Tuesday morning.

Feds approve Colorado’s inclusion of gender-affirming care in essential benefits benchmarking

The additions to essential health benefit coverage in 2023 are headlined by the gender-affirming care, which will expand the services insurance companies have to cover beyond what they already include in that vein.

“Coverage varies greatly by insurance company, and is not always comprehensive and may include explicit exclusions for certain services, even if a health care provider determines a service to be medically necessary,” the governor’s office said in a news release.

CMS say the additional care that will be covered include eye and lid modifications, face tightening, facial bone remodeling, breast and chest reduction and construction and laser hair removal.

“Colorado’s expansion of their essential health benefits to include gender-affirming surgery and other treatments is a model for other states to follow and we invite other states to follow suit,” Brooks-LaSure said in a statement.

Rep. Brianna Titone, D-Arvada, who is Colorado’s first transgender lawmaker, said she was proud of Colorado’s move to include more gender-affirming coverage.

“For too long, too many transgender and nonbinary people have struggled to access the health care they need, despite having health insurance,” she said in a statement. “These services are critical for the health and safety of LGBTQ+ communities and will provide more Coloradans with the agency they need to affirm their identities.”

Other essential health benefits added to Colorado’s coverage by the CMS include a yearly mental health wellness exam from a qualified mental health care provider, the coverage of six annual acupuncture treatments to address substance use disorder, and the addition of 15 drugs that can be used as alternatives to opioids when doctors are writing prescriptions.

Polis and Conway, the Colorado insurance commissioner, said the added coverage would only increase costs by 64 cents per month for people on individual and small-group market plans, which both said would be greatly offset by the long-term benefits.

The state says the new essential health benefits coverage will also apply to Colorado Option plans when they go online for 2023. Officials said about 20% to 25% of Coloradans are covered on individual or small-group health insurance plans.

Josie Nixon, the development coordinator for Out Boulder County, which advocates for LGBTQ+ people, services and programs, said the new benefits “show that Colorado wants to lead the way.”

“Trans people will be able to access the care within Colorado in a more equitable way. Providers will have more access to training because these things are going to become more common,” Nixon said. “Right now, trans people face barriers like costs. It is incredibly expensive to try and self-fund these services. … People will typically take out enormous loans, start GoFundMes, and it should be that we’re using GoFundMe or social media or our own resources to provide care for these residents that we have clinicians and psychiatrists and therapists all saying that these are medically necessary in order for these people to thrive.”

Nixon said they moved to Colorado from Michigan in order to feel more comfortable transitioning and to have better access to health care. They paid out of pocket for many of the expenses and said that crippled their mental health for a time, but that it was the right decision in the long run.

“Without these changes and these medical procedures that I’ve been through, I don’t think I would be standing here today, and I think it’s important for people to recognize that providing access to health care improves a lot of different things in our lives,” Nixon added.

The last time Colorado modified its plan for essential health benefits under the Affordable Care Act was in 2015. The state submitted its plan for 2023 in May after four months of discussions between a working group, consumers, insurance companies and health care providers.

“We’ve made great strides in making health insurance more affordable in Colorado, but this is a huge step in making sure the benefits in that insurance are more inclusive and meaningful,” Conway said in a statement.

The Colorado Association of Health Plans, which represents the health insurance industry, said it believes the new benefits, along with bills passed this past session, would increase premium costs by 1-1.5% each year.

“This does not save people money on health care and will make meeting premium reduction targets for the Colorado Option even more unlikely,” said Amanda Massey, a spokesperson for the group.

Rep. Patrick Neville, R-Castle Rock, claimed the new covered benefits were “bad for the American worker” and amounted to “insurance mandates.”

“Policies like these will only increase costs for Coloradans. They will increase the bureaucratic and regulatory burden on consumers, providers, employers and insurers. Employees will pay the price at the end of the day,” he said in a statement.