Health benefits

Colorado adds gender-affirming care to essential health benefits


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

Colorado residents whose bodies conflict with their gender may find it easier to pay for treatment starting in 2023.

The Centers for Medicaid and Federal Medicaid Services announced Tuesday that they have approved Colorado’s plan for updating the State’s essential health services (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 exam and six acupuncture sessions per year.

Related: Hawaii Calls on Health Plans for More Transparency on Benefits of Gender Transition

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

Basics of the ACA Essential Health Package

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

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

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

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

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

Colorado’s gender-affirming care requirements

A Colorado baseline proposal gives a detailed description of the benefits of care stating the kind that a major medical policy should offer.

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

Colorado states that additional covered services should include, at a minimum, these 12 elements:

  • Blepharoplasty (changes in the eyes and eyelids)
  • Firming of the face / forehead and / or neck
  • Facial bone reshaping for facial feminization
  • Genioplasty (reduction of chin width)
  • Rhytidectomy (cheek, chin and neck)
  • Cheek, chin and nose implants
  • Lip lift / augmentation
  • Mandibular angle augmentation / creation / reduction (jaw)
  • Orbital remodeling
  • Rhinoplasty (nose reshaping)
  • Laser hair removal or electrolysis
  • Breast / thoracic surgery

Other states

Many states have passed laws or regulations that prohibit health insurers from discriminating against people based on their gender identity. In many cases, for example, state rules require insurers to cover procedures for handling gender identity issues if they cover the same procedures for registrants without gender identity issues.

Washington State has a new law which will require state health insurers to cover medically necessary gender affirmation treatments, including cosmetic services such as facial feminization surgeries, tracheal shaves and hair electrolysis, and others forms of care, such as mastectomies, breast reductions and breast implants.

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

The cost

Federal regulators are requiring states to conduct analyzes of essential health benefit proposals to verify that the EHB package will not be leaner or richer than what the federal government considers good benchmarks.

Actuarial consultants from the Wakely Consulting Group performed an analysis of the Colorado EHB proposal dated May 7.

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

The consultants arrived at this 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 American adults identify as transgender, and they estimated that at least 80% of transgender people would end up seeking coverage for surgery, if all the obstacles were met. abolished, between 20 and 60 years.

The team also included cost estimates for other new elements of the EHB package in their review.

They predicted that the element of the annual mental health exam would increase total claim costs by 0.02%, and that the element of acupuncture, which was added to provide chronic pain patients with an alternative. opioids, would increase claim costs by 0.08%.

The total cost of referral plan coverage in Colorado is now approximately $ 4,200 per year.

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

  • Annual Mental Health Wellness Review: 84 cents per year
  • Gender affirming care: $ 2.52 per year
  • Acupuncture: $ 3.36 per year

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