CMS announces approval of Colorado’s insurance plan to expand EHBs

The Centers for Medicare & Medicaid Services (CMS) announced the approval of the 2023 minimum health care coverage Colorado benchmark health insurance plan on Tuesday. The plan establishes the minimum standards for essential health benefits (EHBs) in Colorado for small group plans — for employers with less than 100 employees — and individual plans. 

The plan expands covered care to include mental health wellness exams, expanded drug formularies for opioid alternatives, and gender-affirming care.

 

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Gov. Jared Polis said:

“This is a great day for health care in Colorado. This plan expands access to mental health services for Coloradans while helping those fighting substance abuse to overcome their addiction. This improves care for Coloradans and ensures that even more Coloradans have access to help when they need it.”

The Colorado Division of Insurance (DOI) held meetings with stakeholders, consultants, insurance companies, and advocates to create this plan for CMS, which was submitted in May 2021. DOI’s meetings were open to the public and included a public comment period for input beyond the scheduled meetings. 

The included mental health wellness exams are one-time visits of about 45-60 minutes long per plan per year. These visits will act as screenings for mental health and provide a warm hand-off to ongoing mental health treatment. The visit can also include consultations on lifestyle choices, behavioral health screenings, and discussions of potential medication options. 

These wellness exams were added to the approved plan through House Bill 21-1068, which requires health plans to cover an annual mental health wellness exam upon the confirmation from the United States Department of Health and Human Services. Large employer plans are required to institute these exams by Jan. 1, 2022, and small group and individual plans are required to by Jan. 1, 2023. 

The approved plan also includes expansions of the drugs insurance companies are required to cover in formularies to include alternatives to opioids for pain management. The plan adds 12 drugs and will cover up to six acupuncture visits per year. 

These measures intend to address substance abuse disorder, opioid use disorder, and opioid overdose deaths in Colorado. According to the Colorado Health Access Survey (CHAS) from the Colorado Health Institute (CHI), 11.9% of people over 18 experience substance abuse in Colorado, which is 4.2% higher than the national average. In Colorado, 564 opioid overdose deaths were reported in 2018, according to the National Institute on Drug Abuse. 

Sen. Brittany Pettersen, who has been a strong advocate for substance use disorder in the Legislature, said:

“Today’s announcement is an exciting step that furthers Colorado’s investments in the state’s behavioral health and substance abuse disorder prevention programs that ensures access to these critical services is affordable and accessible for all. The pandemic has taken a toll on all of us and as Colorado rebounds, improving these services will go a long way in making every Coloradan healthier and happier.”

With this approval, Colorado became the first state in the country to explicitly include comprehensive gender-affirming care services in its plan. Gender-affirming care is the mental and physical health services provided to help align a transgender person’s body with their gender identity. Currently, coverage varies greatly by insurance companies, may not be comprehensive, or may exclude certain gender-affirming services. Lt. Gov. Dianne Primavera said:

“Today’s announcement means that gender diverse Coloradans can stop guessing at how and which gender-affirming benefits are included in their coverage.”