Momentum building around access to care in the transgender community: Part I

Posted June, 6 2014 by Amanda


Guest post by Milo Primeaux, Health Counselor at Community Service Society of NY and HCFANY LGBT Task Force Member

In this two-part blog, we explore recent changes at the state and federal levels that will improve access to health care for the transgender community. Here in Part I, we outline how a recent change to Medicare policy means that more transgender people will be able to access health benefits for transition-related treatments. Part II will explore a recent change to New York’s birth certificate policy that will make it easier for transgender New Yorkers to access official documents that reflect their identities.

A transgender person is someone whose sex at birth is different from who they know themselves to be on the inside. Many transgender people are prescribed hormones by their doctors to change their bodies, and some undergo surgery as well. Most insurance plans explicitly exclude coverage for these services when prescribed for transgender people, even though the same treatments may be covered for non-transgender people who have other conditions. For example, a plan might cover a double mastectomy for a woman who is at a high risk for breast cancer, but not for a transgender man for whom a double mastectomy (aka masculinization of the chest) would be gender-affirming. Such categorical exclusions in insurance policies – ones that specifically single out transgender people as not being eligible for coverage of treatment that is medically necessary to them – are blatantly discriminatory, but extremely common.

However, a recent federal decision may signal that change is coming…

On May 30, 2014, the U.S. Department of Health and Human Services (HHS) Departmental Appeals Board overturned a long-standing policy that categorically excluded coverage for any transition-related medical services for transgender Medicare beneficiaries. The original policy had been based on inconclusive findings (i.e. not enough research) from the early 1980s regarding the safety and effectiveness of “transsexual surgery.” After reviewing several briefs and studies submitted by advocacy organizations opposing the antiquated policy, the Appeals Board found that the policy’s “stated bases for its blanket denial of coverage for transsexual surgery are not reasonable.”

This decision is critically important for several reasons. First, transgender Medicare beneficiaries – that is, those who are disabled or are 65 years of age or older – can now access coverage for medically necessary transition-related treatment. Obtaining coverage for the treatment will require the same process as for any other – the Medicare beneficiary needs approval by a medical provider who accepts Medicare, and they must pay any applicable deductible. Now, if a Medicare plan denies coverage for transition-related services for a transgender beneficiary, it will have to be on a basis like medical necessity, which can be appealed and won.

Second, this victory may positively impact whether private insurance and state-run Medicaid programs for low-income people will start to cover transition-related services for transgender people. This is because Medicare often sets the standard for coverage and reimbursement rates nationwide. Advocates can now use this Medicare decision, including its citations to pertinent scientific research, to convince their states to make transgender healthcare more accessible across the country.

This change in Medicare policy comes in the wake of other recent administrative victories related to transgender care. For example, several state agencies that oversee private insurance plans have issued policy bulletins effectively banning transgender-related categorical exclusions in most private insurance policies sold in those states. HCFANY’s LGBT Task Force is currently collaborating with other advocates to explore how we can use these effective strategies to prohibit health coverage discrimination against transgender people here in New York.

Stay tuned for Part II to read about how a recent New York State policy change about birth certificates will actually have a significant impact on transgender health…

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