STATEWIDE– The Centers for Medicare & Medicaid Services has formally approved gender-affirming care in individual and small group health insurance markets as part of Colorado’s Essential Health Benefit benchmark.

According to state figures, the small group and individual health insurance markets cover about 20 percent of Coloradans.

This step is in alignment with the Biden administration’s work to remove health care barriers for transgender persons. This plan will enhance access to coverage for gender-affirming care that meets individual needs, rather than the past model that was a “one-size-fits-all” framework.

Changes to the plan will allow access to a wider range of services for transgender individuals in addition to benefits already covered such as eye and lid modifications, face tightening, facial bone remodeling for facial feminization, breast/chest construction, and reductions and laser hair removal.

Colorado is also adding EHBs in the benchmark plan to include mental wellness exams and expanded coverage for 14 prescription drug classes. All changes will take effect on January 1, 2023. 

“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.” 

“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.

Gender-affirming care is considered a standard level of care by the American Medical Association, the American Academy of Family Physicians, and the American Psychiatric Association. Transgender patients often face discrimination when trying to access medically necessary health care services that affirm their gender identity. 

“This has been such a long fight, not just to get insurance to cover this, but to have people to understand that this is essential healthcare,” Inside Out Communication Manager Alissa Smith said.

Inside Out, a non-profit organization serving the LGBTQ+ community in El Paso County says nearly half of their organization is transgender or gender non-conforming. They said this new requirement is also suicide prevention.

If someone is referred to by their correct pronouns it can prevent suicide by up to 56% and so having gender-affirming surgery, hormone replacement surgery, being able to access this care can prevent suicide in the long term and no matter who we are, no matter what our views we can all agree that we want people to feel comfortable in their own skin,” Smith added.

The Affordable Care Act requires non-grandfathered health plans in the individual and small group markets to provide coverage in 10 categories of EHBs such as preventive and wellness services, chronic disease management, maternity, and newborn care, hospitalization, prescription drugs, mental health, and substance use disorder services, behavioral health treatment, and lab services. 

CMS regulations allow states the flexibility to develop state-specific “benchmark” plans that detail the specific services covered among these broad categories based on a typical employer plan offered in the state. 

Costs for transition procedures range from ten’s of thousands of dollars, however, the new mandate will lead to increased health insurance costs.

“You may see GoFundMe’s everywhere of hey help me fund my top surgery, help me fund this it is so dystopic that people have to ask their friends to donate into their own healthcare because it is just prohibitively expensive,” Smith added. “One thing that this does that we are really excited about is standardizing what insurances need to cover right so that will eliminate the confusion.”

CMS recognizes that expanded, gender-affirming coverage improves health care for the LGBTQ+ community by reducing high rates of depression, anxiety, and suicide attempts and decreases substance use, improves HIV medication adherence, and reduces rates of harmful self-prescribed hormone use.