CO Will Add LGBTQ+ Care As Marketplace Essential Health Benefit

Updated 10/13/21: This article has been updated to include a statement from Andy Marra, executive director of the Transgender Legal Defense & Education Fund (TLDEF).

Colorado has received approval to make gender-affirming care an essential health benefit on the individual and small group health insurance marketplaces 

“Health care should be in reach for everyone; by guaranteeing transgender individuals can access recommended care, we’re one step closer to making this a reality,” said HHS Secretary Xavier Becerra. “I am proud to stand with Colorado to remove barriers that have historically made it difficult for transgender people to access health coverage and medical care.”

Currently, the state’s markets conform to the ten essential health benefits outlined under the Affordable Care Act, which include mental and behavioral healthcare, maternal and newborn care, preventive care and wellness programs for chronic disease management, and more.

However, starting on January 1, 2023, Colorado’s essential health benefit requirements for individual and small group health insurance markets will also encompass LGBTQ+ care. 

LGBTQ+ care can include a number of procedures and benefits. For instance, plans on the individual and small group health insurance marketplaces will have to cover eye and lid modifications, facial feminization, breast and chest reconstructions, hair removal, and other treatments.

According to the press release, adding these benefits into the essential health benefits category will prevent health plans from applying a singular approach to all individuals who identify as part of the LGBTQ+ community.

Apart from the new essential health benefits requirement, the state will also require a broader range of mental healthcare treatments and prescription drug classes.

“Health care should be accessible, affordable and delivered equitably to all, regardless of your sexual orientation. To truly break down barriers to care, we must expand access to the full scope of health care, including gender-affirming surgery and other treatments, for people who rely on coverage through Medicare, Medicaid & CHIP and the Marketplaces,” said CMS Administrator Chiquita Brooks-LaSure. “Colorado’s expansion of their essential health benefits to include gender-affirming surgery and other treatments is a model for other states to follow and we invite other states to follow suit.”

To Human Rights Campaign Interim President Joni Madison, the decision represented an important step, in Colorado.

“Today's decision by the Center for Medicare and Medicaid Services (CMS) will make it easier and less cost-prohibitive for transgender Coloradans to seek gender-affirming care. Expanding access to transition-related care in Colorado's Essential Health Benefits benchmark is an important sign of progress toward equality, not just because it makes the lives of transgender people easier, but because it designates a broad range of gender-affirming care as essential in the eyes of the government consistent with medical standards,” Madison told HealthPayerIntelligence in an emailed statement.

“The Human Rights Campaign applauds Colorado Governor Jared Polis for his advocacy and hard work and the Biden Administration for recognizing the dignity transgender people deserve when seeking the gender-affirming care they need. Gender-affirming care should be available to all transgender people regardless of their insurance plan or where they live.”

Andy Marra, executive director of the Transgender Legal Defense & Education Fund (TLDEF), joined Madison in emphasizing the positive impact that this decision would have on LGBTQ+ patients, specifically individuals in the transgender community.

“Transgender Coloradans and their families have a reason to celebrate as the state will recognize gender-affirming care as an essential health benefit. In addition to existing state and federal protections, this decision makes it even more plain that health insurance plans offered by a small group employer or purchased on the state marketplace must guarantee coverage for gender-affirming care,” Marra shared with HealthPayerIntelligence in an emailed statement.

The LGBTQ+ community still faces discrimination in the US healthcare system. In 2020, when the Trump Administration finalized changes to the HHS nondiscrimination rule that reduced the language related to sexual and gender discrimination, payers pushed back. Leading payers and payer organizations argued that the adjustments would allow for gender discrimination.

For example, around the same time that the previous administration finalized the rule, an article in JAMA Open Network revealed patterns that were discriminatory against patients with HIV related to prior authorizations in the South.

Payers have the power to support treatments that are backed by influential provider organizations, such as the WPATH Standards of Care. They can also eliminate blanket exclusions for members and correct internal policies.