Some Colorado insurers will be required to expand essential health benefits to cover substance use, mental health and gender-affirming care

October 12, 2021
A screenshot shows the homepage of the Connect for Health Colorado website on Oct. 12, 2021.A screenshot shows the homepage of the Connect for Health Colorado website on Oct. 12, 2021.Connect for Health Colorado
A screenshot shows the homepage of the Connect for Health Colorado website on Oct. 12, 2021.

Colorado has received approval from the Biden administration to require some insurance plans to expand coverage for Coloradans battling addiction and other mental and behavioral health problems.

“Now with a 2023 benchmark plan, we're expanding access to services on the individual and small group market,” said Gov. Jared Polis, of the minimum health care coverage requirements, which were okayed by the Centers for Medicare and Medicaid Services (CMS). “Colorado is one of the first states in the nation to include an annual mental health wellness exam.”

The plan sets essential health benefits in Colorado for individual plans, for people not covered by an employer, as well as small group plans, which are designed for workplaces with fewer than 100 workers.

Sen. Brittany Pettersen, a Democrat and longtime legislative advocate for expanding coverage, called it, “a really big step forward.”

The move comes with Colorado still in the midst of an unrelenting opioid crisis, most recently fueled in part by a sharp rise in overdoses of fentanyl. Fatal overdoses from the drug, a synthetic opioid far stronger than heroin, happen more frequently in Colorado than the national average.

Pettersen said historically Colorado health plans cover physical but not mental health exams.

“So this is a really important when we talk about prevention and making sure that people are getting access to the healthcare that they need and the screenings upfront before they go down a path of ultimately using drugs, becoming addicted to self-medicate for something like anxiety or depression, because they didn't get to catch that up front,” said Pettersen, whose mother has battled addiction.

Pettersen said when lawmakers talked to doctors about not prescribing opioids and addressing pain by prescribing alternative medications or treatment, “they often talk about how this (opioids) is usually the only thing covered by our insurance. That is absolutely unacceptable.”

Affected plans cover about 500,000 Coloradans

Tuesday's announcement pertains just to the individual and small group markets, which cover about 500,000 people in the state. Those are the markets addressed by the federal Affordable Care Act, the ACA. Benchmark plans and their essential health benefits are a feature of the ACA. When Colorado, or any state, seeks to update its benchmark plan, it must first gain CMS approval. 

The administration’s approval also makes Colorado the first state to explicitly include gender-affirming care services in its benchmark plan. The care describes health services that help align a transgender person’s body with their gender identity. Insurers operating in Colorado already cover many gender-affirming procedures in order to comply with the state's anti-discrimination statutes. But the Polis administration believes that making specific mention of gender affirmation procedures within the benchmark plans for the insurance exchange will go a long way toward standardizing the coverages and making them more comprehensive.

Top Biden administration officials joined Polis, Lt. Gov. Dianna Primavera and his team for the announcement.

“Healthcare should be accessible, affordable, and delivered equitably to all regardless of your sexual orientation or gender identity,” said CMS Administrator Chiquita Brooks-LaSure. She said the Biden-Harris administration, through the Centers of Medicare and Medicaid services “is committed to removing barriers to coverage and care for LGBTQ plus people.”

Human costs versus premiums

Asked if costs to insurers for the expanded benefits would ultimately be passed on to consumers, Polis didn’t answer directly, but said the human and financial costs of the state not successfully dealing with opioid dependency and mental health problems cost more.

“So preventing that by offering alternatives for pain management and also alternatives for recovery from opioid dependency absolutely saves money on healthcare and saves lives,” the governor said. 

A group representing insurers, the Colorado Association of Health Plans, said they fully support ensuring Coloradans have access to high quality, affordable care, but they feel certain these changes will result in increased costs for all policy holders.

"Additional benefits come with additional costs that by law must be reflected in the price of premiums," said executive director Amanda Massey. CAHP estimates the new 2023 benchmark plan benefits, in addition to the bills passed by the Colorado Legislature in 2021, will cost Coloradans 1 percent to 1.5 percent more for their premiums annually.

"This does not save people money on healthcare and will make meeting premium reduction targets for the Colorado Option (the state's new insurance plan) even more unlikely," Massey said.

Insurance commissioner Michael Conway said the state’s analysis of the changes showed  “huge” long-term benefits. “The cost of all of these pieces that we're building into the benchmark is negligible,” said Conway, who said insurance companies were part of the stakeholder process in developing the plan.

“We want to support patients and providers as we create a more inclusive and affirming healthcare system,” said Primavera. She called increasing access to gender-affirming care is also “an important tool in our arsenal to improve mental and behavioral health outcomes for Colorado and specifically our LGBTQ plus neighbors.” She noted transgender and nonbinary Coloradans experience anxiety and depression at much higher rates than their cisgender peers.

Other states could follow suit and offer similar changes, said Brooks-Lasure, who didn’t offer specifics.

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