Colorado adds gender-affirming care to essential health benefits

It will be added to the list of products or services that must be included in a policy package without imposing an annual or lifetime benefits maximum.

Other states have used state laws and regulations to set minimum requirements for gender-affirming care coverage, but Colorado is the first state to build the requirements into its EHB package.

Colorado residents with bodies that conflict with their gender may have an easier time paying for treatment starting in 2023.

The federal Centers for Medicaid and Medicaid Services announced Tuesday that it has approved Colorado’s plan for updating the state essential health benefits (EHB) package. The plan includes a minimum level of coverage for gender-affirming care.

The new Colorado EHB package also includes access to an annual mental health wellness exam and six acupuncture sessions per year.

Related: Hawaii asks health plans for more transparency on gender transition benefits

Other states have used state laws and regulations to set minimum requirements for gender-affirming care coverage, but Colorado is the first state to build the requirements into its EHB package, federal officials said in the approval announcement.

ACA essential health benefits package basics

In the Affordable Care Act system, which took effect in 2014, a state’s EHB package is the list of health care products and services that a major medical insurance policy must cover.

With the exception of some bare-bones “catastrophic plans” sold to young adults and to high-income uninsured people, every individual or small group major medical insurance policy sold in the United States now must cover at least about 60% of the actuarial value of the EHB package.

A policy must cover any product or service included in the EHB package without imposing an annual or lifetime benefits maximum.

The Affordable Care Act itself lists 10 things a major medical insurance policy must cover: hospitalization; outpatient services; emergency services; prescription drugs; lab tests; maternity and newborn care; behavioral health care; chronic disease management and preventive services efforts endorsed by federal advisory panels; dental and vision care for children; and rehabilitation services.

A state can adjust its EHB package to reflect what popular government and commercial plans offer its residents.

The Colorado gender-affirming care requirements

A Colorado benchmark plan proposal gives an extensive description of the gender-affirming care benefits a major medical policy should offer.

The definition of gender-affirming care includes “medically necessary treatment for gender dysphoria, such as hormone therapy and genital non-genital surgical procedures,” according to the proposal.

Colorado says additional covered services should include, at a minimum, these 12 items:

Other states

Many states have adopted laws or regulations that prohibit health insurers from discriminating against people based on gender identity. In many cases, for example, state rules require insurers to cover procedures for dealing with gender identity concerns if they would cover the same procedures for enrollees with no gender identity concerns.

Washington state has a new law that will require health insurers in the state to cover medically necessary gender-affirming treatments, including cosmetic services such as facial feminization surgeries, tracheal shaves and hair electrolysis, and other forms of care, such as mastectomies, breast reductions and breast implants.

New York state adopted regulations in June that require health insurers there to cover “all gender-affirming treatments for gender dysphoria,” including “specialized psychological assessments, puberty-suppressing hormonal treatment, feminizing/masculinizing hormone therapy, augmentation mammoplasty, mastectomy, hysterectomy, salpingo-oophorectomy, phalloplasty or metoidioplasty (with or without urethral reconstruction), vaginectomy, scrotoplasty, implantation of erection and/or testicular prostheses, penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty, liposuction, lipofilling, thyroid cartilage reduction, pectoral implants, gluteal augmentation, hair reconstruction, voice surgery, and facial feminization surgery.”

The cost

Federal regulators require states to conduct analyses of essential health benefits proposals, to verify that the EHB package will not be skimpier or richer than what the federal government thinks of as good benchmark plans.

Actuarial consultants from Wakely Consulting Group conducted an analysis of the Colorado EHB proposal that’s dated May 7.

The consultants predicted that adding a gender-affirming care mandate to the EHB package could increase total benefits costs by about 0.04%.

The consultants came up with that estimate by looking at the cost of the individual services that are part of gender-affirming care.

The consultants cited research indicating that about 0.56% of U.S. adults identify as transgender, and they estimated that at least 80% of transgender people would eventually seek coverage for surgery, if all barriers were removed, between the ages of 20 and 60.

The team also included cost estimates for other new EHB package items in their review.

They predicted that the annual mental health wellness exam item would increase total claim costs by 0.02%, and that the acupuncture item — which was added to give patients suffering from chronic pain an alternative to opioids — would increase claim costs by 0.08%.

The full cost of benchmark plan coverage in Colorado is now about $4,200 per year.

For an enrollee with a benchmark plan that cost $4,200 per year, here’s how the percentage costs would translate into dollar values:

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