For the first time, the Centers for Medicare & Medicaid Services (CMS) approved a request to provide gender-affirming care in the individual and small group health insurance markets as part of Colorado’s Essential Health Benefit (EHB) benchmark. Today’s landmark step is aligned with the Biden-Harris Administration’s efforts to address health care disparities by removing longstanding barriers and expanding access to care for transgender persons.
Colorado’s new EHB-benchmark plan will enhance access to coverage for gender-affirming care that meets individual needs and discourages the use of a “one-size-fits-all” framework for transgender persons seeking medical care. Changes to the EHB-benchmark plan will allow access to a wider range of services for transgender individuals in addition to benefits already covered. Such treatments will include eye and lid modifications, face tightening, facial bone remodeling for facial feminization, breast/chest construction and reductions, and laser hair removal. The state is also adding EHBs in the benchmark plan to include mental wellness exams and expanded coverage for 14 prescription drug classes. These changes will take effect beginning 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. “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.”
Gender-affirming care is considered a standard level of care by the American Medical Association, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Psychiatric Association. Transgender patients often face discriminatory hurdles in accessing medically necessary health care services that affirm gender identity.
The Affordable Care Act (ACA) requires non-grandfathered health plans in the individual and small group markets to provide coverage in 10 categories of EHBs, including 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.
CMS recognizes that expanded, gender-affirming coverage vastly improves health care outcomes for the LGBTQ+ community, reduces high rates of depression, anxiety, and suicide attempts as well as decreases substance use, improves HIV medication adherence, and reduces rates of harmful self-prescribed hormone use.
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