Gender-affirming care services to be covered under Colorado’s benchmark plan

Colorado’s new benchmark plan requires coverage for “medically-necessary treatment for gender dysphoria, such as hormone therapy and genital and non-genital surgical procedures.” Additionally, plans will be required to provide coverage for, at a minimum, the following specific services:

1. Blepharoplasty (eye and eyelid modification)
2. Face/forehead and/or neck tightening
3. Facial bone remodeling for facial feminization
4. Genioplasty (chin width reduction)
5. Rytidectomy (cheek, chin and neck)
6. Cheek, chin and nose implants
7. Lip lift or augmentation
8. Mandibular angle augmentation, reduction or creation (jaw)
9. Orbital recontouring
10. Rhinoplasty (nose reshaping)
11. Laser or electrolysis hair removal
12. Breast/chest augmentation, reduction or construction

Colorado’s changes could signal start of growing trend

Although Colorado is the first state to include gender-affirming care as an essential health benefit in its proposed benchmark plan, it has carved a clear path for other states to enact similar changes.  Members of the Biden administration have expressed approval of Colorado’s changes, and CMS administrator Chiquita Brooks-LaSure noted in a statement that Colorado serves as “a model for other states” and that CMS “invite[s] other states to follow suit.” In addition, several health care organizations, including the American Medical Association, the American Academy of Pediatrics and the American Psychiatric Association, recognize gender-affirming health care services as a standard level of care. Thus, while Colorado is the first state to expand coverage for gender-affirming care, it may not be the last.  Payors in the individual and small group markets should closely monitor regulatory developments in their applicable states to determine whether they will similarly mandate coverage for gender-affirming care.

Client Alert 2021-272