Oregon is mandating Medicaid coverage for gender dysphoria treatment, bringing it in parity with the state's progressive commercial market and also putting pressure on other states and insurers.
The state's Health Effectiveness Review Commission has approved coverage of gender reassignment surgery, hormone therapy and other treatments for transgender patients enrolled in the Oregon Health Plan, the state's Medicaid program.
Since 2012, Oregon has required commercial individual and small group insurers, and last year the state extended coverage to the public employees health plan; the Health Evidence Review Commission's latest decision will make it the fourth Medicaid program to pay for gender dysphoria treatment, along with California, Vermont and Washington D.C.
The Health Evidence Review Commission declined to recommend Medicaid coverage for treatment of gender dysphoria or gender identity disorder in 1999, but in April, the board took up consideration of the issue again, in part because in the intervening years organizations such as the American Medical Association, the American Psychiatric Association, and the American Academy of Family Physicians came out in support of broad access to hormonal and surgical treatment.
Once the Oregon Health Authority finalizes the policy, starting this fall or early next year, transgender Oregon Medicaid beneficiaries will eligible for coverage of psychotherapy and medical visits, and those with gender dysphoria documented by at least two mental health professionals will have access to puberty suppression medication, cross-sex hormone therapy and gender reassignment surgery.
"This vote means that, for the first time in the history of the Oregon Health Plan, a comprehensive continuum of healthcare will be available for the treatment of gender dysphoria," said Danielle Askini, the policy director at Basic Rights Oregon, a gender advocacy group.
The decision by Oregon to cover gender hormone and surgical reassignment in Medicaid may be an impetus for other states to pay for the services, as well as commercial insurers.
However, the new requirements in Oregon and other states with mandated coverage may create some new complexities and stir debate over eligibility criteria, which isn't always spelled out in the new states laws. While gender advocacy groups may seek wide accessibility, payers covering the treatment are setting up pathways that require extensive evaluations and medical criteria for treatments like hormone therapy and reassignment surgery.
In California, the 2013 Insurance Gender Nondiscrimination Act in 2013, bars health plans from limiting benefits due to an enrollee's sex, but does not include a list of specific treatments that must be covered. As such, insurers like Blue Shield of California are covering gender counseling, hormone therapy and reassignment surgery, while putting in place criteria that must be fulfilled and denying reimbursement for certain procedures when they are deemed cosmetic.
Blue Shield of California's policy, for instance, stipulates that members receiving genital reconstruction surgery spend 12 months living in the desired gender role and two recommendations from mental health professionals, while augmenting treatments that are considered cosmetic, like brow reduction and chin adjustments, are not covered in full.
Although insurers are being given some discretion over medical necessity, California's law and others may be interpreted fairly broadly. Already, California's Department of Managed Care has overturned a number of coverage denials.