Health benefits

Some Colorado insurers will be required to extend essential health benefits to cover substance use, mental health and gender care


Colorado has received approval from the Biden administration to require certain insurance plans to expand coverage for Coloradans battling drug addiction and other mental and behavioral health issues.

“Now, with a 2023 baseline plan, we are expanding access to services in the individual and small group market,” Governor Jared Polis said of minimum health care coverage requirements, which have been approved by the Centers for Medicare and Medicaid Services (CMS). “Colorado is one of the first states in the country to include an annual mental health wellness review.”

The plan sets out essential health benefits in Colorado for individual plans, for people not covered by an employer, as well as for small group plans, designed for workplaces with fewer than 100 workers.

Senator Brittany Pettersen, Democrat and longtime legislative activist for extension of coverage, called it a “very big step forward”.

The move comes as Colorado remains in the throes of a relentless opioid crisis, recently fueled in part by a surge in fentanyl overdoses. Fatal drug overdoses, a synthetic opioid far more potent than heroin, occur more frequently in Colorado than the national average.

Pettersen said historically Colorado’s health plans covered physical health exams but not mental health exams.

“So that’s very important when we talk about prevention and making sure that people have access to the health care they need and to the testing before they embark on the path of drug use, of becoming addicted. to self-medicate for something like anxiety or depression, because they couldn’t figure it out from the start, ”said Pettersen, whose mother has struggled with drug addiction.

Pettersen said that when lawmakers spoke to doctors about not prescribing opioids and treating pain by prescribing drugs or alternative treatments, “they often explain that these (opioids) are usually the only thing covered by our insurance. . It is absolutely unacceptable. “

The plans concerned cover around 500,000 Coloradans

Tuesday’s announcement is only for individual and small-group markets, which cover about 500,000 people in the state. These are the markets covered by the Federal Affordable Care Act, ACA. Referral plans and their essential health benefits are a hallmark of ACA. When Colorado, or any other state, seeks to update its baseline, it must first get approval from the CMS.

The administration’s approval also makes Colorado the first state to explicitly include gender-affirming care services in its baseline. Care describes health services that help align a transgender person’s body with their gender identity. Insurers operating in Colorado already cover numerous gender affirmation procedures in order to comply with state anti-discrimination laws. But the Polis administration believes that the specific mention of gender affirmation procedures in the reference plans for the insurance stock market will go a long way in standardizing the coverages and making them more comprehensive.

Senior officials in the Biden administration joined Polis, Lieutenant Governor Dianna Primavera and her team in the announcement.

“Health care must be accessible, affordable and provided equitably to everyone, regardless of your sexual orientation or gender identity,” said CMS administrator Chiquita Brooks-LaSure. She said the Biden-Harris administration, through the Centers of Medicare and Medicaid services “is committed to removing barriers to coverage and care for LGBTQ people and older.”

Human costs versus premiums

When asked whether insurers’ costs for the expanded benefits would ultimately be passed on to consumers, Polis did not respond directly, but said the human and financial costs of the state failing to successfully address addiction opioids and mental health problems cost more.

“So preventing this by providing alternatives for pain management and also alternatives for recovery from opioid addiction saves money on health care and saves lives,” governor.

A group representing insurers, the Colorado Association of Health Plans, has said it fully supports Coloradians having access to high-quality, affordable care, but they are confident the changes will lead to increased costs for all policyholders. .

“With the additional benefits come additional costs which by law must be reflected in the price of the premiums,” said Chief Executive Officer Amanda Massey. The CAHP estimates that the new benefits of the 2023 Reference Plan, in addition to the bills passed by the Colorado legislature in 2021, will cost Coloradans 1% to 1.5% more for their annual bonuses.

“This is not saving people money on health care and will make it even more unlikely that the premium reduction targets for the Colorado Option (the new state insurance plan) will be met.” Massey said.

Insurance Commissioner Michael Conway said the state’s analysis of the changes showed “huge” long-term benefits. “The cost of all of these parts that we put into the benchmark is negligible,” said Conway, who said insurance companies were part of the stakeholder process in developing the plan.

“We want to support patients and providers as we create a more inclusive and empowered health system,” said Primavera. She called increasing access to gender care is also “an important tool in our arsenal to improve mental and behavioral health outcomes for Colorado and in particular our older LGBTQ neighbors.” She noted that transgender and non-binary Coloradans suffer from anxiety and depression at much higher rates than their cisgender peers.

Other states could follow suit and propose similar changes, said Brooks-Lasure, who did not provide details.