Colorado first state to require some health insurance plans to cover gender-affirming care

Starting in 2023, health insurance plans covering about one-quarter of the market in Colorado will have to pay for gender-affirming care, some additional mental health services and pain-management alternatives like acupuncture.

The changes will affect plans sold on the individual and small group markets - so it won't apply to people who get their insurance from large employers or government programs like Medicare.

Gender-affirming care is an umbrella term for services to transgender or nonbinary people, which can include hormone treatments, permanent facial hair removal, counseling, speech therapy, or surgery. Cisgender people sometimes also seek gender-affirming care, such as breast reconstruction after a mastectomy (though they may not think of it in those terms).

"Today marks the first time that a state has looked to add gender-affirming care as an essential health benefit," said Chiquita Brooks-LaSurek, administrator of the federal Centers for Medicare and Medicaid Services, who traveled to Colorado to make the announcement with Gov. Jared Polis. "Hopefully it marks a historic beginning."

The state legislature would need to act in order to require large employers' insurance plans to cover gender-affirming care.

Transgender people who have received gender-affirming care have lower rates of depression than those who were denied care, and are less likely to report thoughts of suicide.

"We know that gender-affirming care is vital to the mental health of transgender and nonbinary Coloradans," Marvyn Allen, One Colorado's health equity and training director, said in a statement. "For too many, gender-affirming care is unaffordable and unattainable. … We are particularly pleased by today's decision because of the inclusion of procedures such as facial feminization surgery and breast/chest surgeries, to name a few which were previously considered cosmetic and excluded from insurance coverage."

Colorado Insurance Commissioner Michael Conway estimated the new benefits will cost about 64 cents per customer each month. Polis said in a news conference that they will ultimately save money by reducing the odds of serious mental health problems in the future.

"I had to be convinced this will save more than 64 cents per month," he said.

The requirement that plans cover an annual mental health check-up and alternatives to opioids came from bills passed in the most recent legislative session, which also require large-group plans to offer the same coverage. The gender-affirming care requirements came from an administrative process, with the Division of Insurance consulting with stakeholders before asking the federal Centers for Medicare and Medicaid Services for permission.

Sen. Brittany Pettersen, a Jefferson County Democrat, said the requirement to cover non-drug pain treatments, like acupuncture, will give patients options to avoid the risk of addiction from opioids. Some studies have found acupuncture provides pain relief, though debate is ongoing about how much of the improvement is due to a placebo effect.

"For decades, we had a system that incentivized overprescribing," she said. Doctors "often talk about, 'This (opioid medication) is the only thing covered by insurance.' That is unacceptable."

The Centers for Medicare and Medicaid Services had to approve any new requirements in the state's "benchmark" plan, which dictates what must be covered in individual market and small group plans. States tend to watch each other's health policy changes, so it's possible others will decide to follow Colorado in expanding benefits, Brooks-LaSure said.