Just as American society's views and acceptance of transgender issues are evolving, insurers are facing choices, challenges and uncertainty in adapting coverage policies for LGBT.
While the Affordable Care Act established a LGBT non-discrimination guarantee for federally-financed insurance, specific national rules for the provision have not yet been developed, leaving uncertainty for insurers and consumers, especially when it comes to transgender transition care and reassignment surgery, treatments that can cost many thousands of dollars per person.
There's currently a patchwork of availability for gender reassignment surgery (GRS). Medicare, federal agency employee health programs and some states require coverage for it and related services, while other states require coverage in individual and small group plans or Medicaid. And in markets without regulatory directives, like large group plans, different insurers are setting their own pace and clinical requirements for how members can access GRS, hormone therapy and other services.
"Insurance companies are making up their own rules as they go along," as Anand Kalra, program administrator at the Transgender Law Center, put it for Kaiser Health News.
Insurance coverage for GRS and transition care has been changing only recently, to meet the new mainstream medical consensus that individuals with gender dysphoria should be able to access surgery, hormone therapy and counseling.
Earlier this year, the Department of Health and Human Services reversed a 1981 Medicare decision and removed a transgender health coverage exclusion, opening the door for American seniors to access gender reassignment surgery, hormone therapy and services related to their new gender.
California, Massachusetts, Oregon, Vermont and Washington D.C. all require Medicaid coverage for gender reassignment surgery, and in October, Oregon became the first state with Medicaid-covered puberty-suppression treatment for adolescents, an approach supported by LGBT advocates that leaves open the option of reassignment to youth with gender dysphoria.
In commercial insurance currently, gender transition coverage remains something of a gray area and rather variable when it comes to access across payer-type and medical necessity policies. California, Colorado, Connecticut, Maryland, Oregon, Vermont and Washington D.C. have issued guidance interpreting the ACA's non-discrimination provision to require coverage for transition-related care in exchange policies -- although there is still a fair amount of ambiguity in reassignment surgery.
For instance, does GRS extend to facial surgery, or are those adjustments cosmetic? Will each plan's provider network need include doctors and facilities to perform GRS, or will drug formularies have to include hormone suppression or maintenance drugs?
In California, one woman's experience chronicled by Kaiser Health News suggest the issue will be complex to standardize.
Enrolled in a Blue Shield of California exchange plan, Palm Springs resident Devin Payne was approved for gender reassignment surgery, 450 miles north at Sequoia Hospital in Redwood City. But the insurer is still figuring out reimbursement for the procedure at an out-of-network provider -- while Payne sits on a $17,000 initial hospital bill.
Federal guidance and regulations on transgender coverage are still forthcoming, and among many priorities on the feds health reform to-do-list. Some insurers and large employers are trying to get ahead of the issue, though, lest they alienate younger generations of educated and progressive workers and consumers, who might be as apt to support gay marriage as they would a single payer health system.
Aetna has announced that in 2015, GRS will be covered in its 33 federal employee health plans and its fully-insured commercial plans, while noting that in 2009 it was the first major insurer to offer the surgery to employees and plan sponsors upon request.
About 20 Blue Cross and large national insurers have at least partial coverage for gender reassignment coverage, and more than 150 of the Fortune 1000 companies cove GRS in their health plans, according to the Human Rights Campaign.