Colorado's updated essential health benefits: What employers need to know
Colorado’s benchmark plan, which will take effect on January 1, 2023, seriously raised the bar for essential health benefits.
It’s not often that a state’s standard submission of a benchmark plan for federal approval would be newsworthy. But recently, Colorado’s benchmark plan, which will take effect on January 1, 2023, seriously raised the bar, establishing various services as essential health benefits (EHBs) which would often not be covered at all. State benchmark plans are used to determine what benefits are considered EHBs in a given state – the ACA defines broad categories of EHBs, but these plans are what issuers in a given market look to for more detail on what specific services need to be given the various protections this status affords.
Related: Hawaii asks health plans for more transparency on gender transition benefits
Notably, the new benchmark plan includes an annual mental health wellness exam as an essential health benefit, with the hope being that this will help with prevention as well as identification and treatment of mental health and addiction issues, with Colorado, like many states, currently experiencing an opioid addiction crisis.
The benchmark plan also establishes as EHBs various treatments relating to gender-affirming services and transition-related care which in normal markets would likely not be covered at all. This includes services like hormone therapy and surgical reconstruction of the genitals, but also includes services that would commonly be regarded as cosmetic or not medically necessary, such as “eye and lid modification, face tightening, facial bone remodeling for feminization, breast/chest construction and reductions, and laser hair removal”.
This marks the first time CMS has approved gender-affirming care as an EHB in the individual and small group markets. This means that fully insured individual and small group policies (those issued to employers with fewer than 100 workers) in Colorado will be required to cover these services. Additionally, although not required to cover every EHB, self-funded plans look to state benchmark plans to determine which benefits are treated as EHBs, and thus any using Colorado will be prohibited from imposing any lifetime or annual maximums on these services.
Not surprisingly, conservative commenters have objected to this move, and it remains to be seen what impact this expansion of benefits may have on premiums in the applicable markets. The release issued by CMS, however, does opine that wider access to these services could have an impact in preventing other conditions, helping to offset any additional direct claim cost in future savings:
“CMS recognizes that expanded, gender-affirming coverage vastly improves health care outcomes for the LGBTQ+ community, reduces high rates of depression, anxiety, and suicide attempts as well as decreases substance use, improves HIV medication adherence, and reduces rates of harmful self-prescribed hormone use.”
CMS and the Biden administration invite other states to follow suit in expanding access to this kind of care – only time will tell how many accept.
Andrew Silverio, Esq., is Compliance & Oversight Counsel for the Phia Group, LLC, primary focusing is on the most complex and emerging legal and regulatory issues, both internally and for our clients as a member of Phia Group Consulting. Andrew is also the Phia Group’s HIPAA privacy officer.
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