It is not often that the standard submission of a state baseline plan for federal approval would be of interest. But recently, Colorado’s benchmark plan, which goes into effect on January 1, 2023, seriously raised the bar, establishing various services as Essential Health Benefits (EHBs) that often would not be covered at all. State benchmarks are used to determine what benefits are considered EHB in a given state – the ACA defines broad categories of EHB, but these plans are what issuers in a given market are looking for more than details on the specific services that must be given to the various protections that this statute offers.
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Notably, the new referral plan includes an annual mental health exam as a critical health benefit, in the hope that this will help in the prevention as well as the identification and treatment of mental health and addiction issues, Colorado, like many states, is currently experiencing an opioid addiction crisis.
The reference plane also establishes as EHBs various treatments regarding gender-affirming services and transitional care which, in normal markets, would likely not be covered at all. This includes services such as hormone therapy and surgical reconstruction of the genitals, but also services that would generally be considered cosmetic or not medically necessary, such as “eye and eyelid modification, facial tightening, bone reshaping of the body. face for feminization, breast / breast construction. and discounts, and laser hair removal ”.
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This is the first time that CMS has endorsed gender affirming care as EHB in 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 they are not required to cover all EHBs, self-funded plans look to the state benchmark plans to determine which benefits are treated as EHB.
Unsurprisingly, conservative commentators have opposed the move, and it remains to be seen what impact this benefit extension may have on premiums in applicable markets. The statement released by CMS, however, believes that wider access to these services could impact the prevention of other conditions, helping to offset any additional direct claim costs in future savings:
“CMS recognizes that expanded, gender-affirming coverage dramatically improves health care outcomes for the LGBTQ + community, reduces high rates of depression, anxiety and suicide attempts, as well as drug use. substances, improves adherence to HIV medications, and reduces rates of harmful self-harm. use of prescribed hormones.
CMS and the Biden administration are urging other states to follow suit by expanding access to this type of care – only time will tell how many are accepting.
André Silverio, Esq., Is Compliance & Oversight Counsel for the Phia Group, LLC, focusing primarily 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 HIPAA Privacy Officer for the Phia Group.