Consumer Advisory: Gender-Affirming Care Insurance Coverage Guide Now Available
Colorado insurance plans must cover these services starting in 2023.
DENVER - Starting this month (January 2023), Colorado becomes the first state in the country to explicitly include gender-affirming care services in its benchmark health insurance plan for essential health benefits (EHBs). A benchmark plan establishes the EHBs within Colorado for commercial plans, meaning that in 2023, individual health insurance plans (plans not from an employer) and small group plans (for employers with less than 100 employees) must cover these services. The Centers for Medicare & Medicaid Services (CMS) approved the new benchmark plan for Colorado in October 2021.
It can be challenging to understand one’s health insurance insurance, and even with the changes due to the benchmark plan, it is also true for transgender people seeking specific medically-necessary services or hormone therapies as part of their treatment plans. To help better understand this new required coverage, the Division of Insurance (DOI), part of the Department of Regulatory Agencies (DORA), has developed a guide on insurance coverage of gender-affirming care medical services for individual and small group health insurance plans.
Please note that the information in this guide is not an exhaustive list of all gender-affirming care procedures, but rather a list of many common services to treat gender dysphoria. It also does not include the different processes, like prior authorization or letters from a provider, that may be required by an insurance company in order to show that it is medically necessary to receive a service or medication.
Gender-affirming health care is an important part of the health care services that every transgender person deserves to achieve their own well-being, and it is not a one-size-fits-all health solution. There are many protections in place in Colorado to ensure access to medically necessary gender-affirming care and non-discrimination in health care based on one’s gender identity.
LGBTQ Health Insurance Coverage Rights in Colorado
Colorado Insurance Regulation 4-2-62 prohibits discrimination in private health insurance plans based on sexual orientation or gender identity. Private insurance plans sold in Colorado and regulated by the Colorado Division of Insurance* cannot do the following.
Inquire about an applicant’s or a beneficiary’s sexual orientation or gender identity in an application for coverage
Deny, cancel, limit, or refuse to issue or renew a policy because of a person’s sexual orientation or gender identity
Deny, exclude, or otherwise limit coverage for medically necessary services, in accordance with generally accepted professional standards of care, based upon a person’s sexual orientation or gender identity
*If your health plan ID card has “CO-DOI” on it, your plan is regulated by the Colorado Division of Insurance and subject to Colorado’s insurance laws and regulations.
People with questions about their health insurance coverage can contact the Division of Insurance Consumer Services Team: 303-894-7490 / DORA_Insurance@state.co.us / https://doi.colorado.gov/ (click on “File a Complaint”).
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About the Division of Insurance:
The Colorado Division of Insurance (DOI), part of the Department of Regulatory Agencies (DORA), regulates the insurance industry and assists consumers and other stakeholders with insurance issues. Visit doi.colorado.gov for more information or call 303-894-7499 / toll free 800-930-3745.
About DORA:
DORA is dedicated to preserving the integrity of the marketplace and is committed to promoting a fair and competitive business environment in Colorado. Consumer protection is our mission. Visit dora.colorado.gov for more information or call 303-894-7855 / toll free 800-886-7675.
