Caitlyn Jenner is rightly being celebrated for choosing to live her life on her own terms. But, as Laverne Cox noted on her Tumblr, “Most trans folks don’t have the privileges Caitlyn and I have now have. It is those trans folks we must continue to lift up.” And, unfortunately, unlike Jenner and Cox, many transgender people still struggle just to get basic health care [PDF]. That’s why recent administrative guidance [PDF] stating that health insurance companies cannot limit coverage of preventive services based on a person’s gender, gender identity, or recorded gender is so important.
Insurance Coverage Based on Need—not a Checkbox
For transgender people, who are more likely to be uninsured than other groups, the Affordable Care Act promised to be a great step forward. But, almost immediately, the newly insured faced a new hurdle. Insurance companies were denying coverage because of a person’s gender identity.
Recommendations for medical services are often based on sex. For example, prostate exams are recommended for men while mammograms are recommended for women. These classifications, though, don’t work for many transgender people. A transgender woman could need a prostate exam while a transgender man could need a mammogram. What matters is medical need—not the gender box checked on a form.
But insurance companies denied claims for these services. In one case, an insurance company initially denied a transgender man treatment for an aggressive form of cervical cancer because of his gender marker. His partner, also a transgender man, changed his gender identity back to female, fearing that he might face a similar denial. No one should be forced to choose between being who they are and receiving timely health care.
The new guidance addresses this problem. It makes clear that coverage should be based on medical need—not gender identity. According to the guidance, if a provider finds that a preventive service, such as a mammogram or a pap smear for a transgender man, is appropriate the insurer must cover the service regardless of the gender indicated in the plan documents. Although this guidance applies specifically to preventive services, insurance companies are now on notice that they can’t use gender identity to deny services.
More Work to Be Done
Although this is a first step, the new guidance doesn’t address another pervasive form of discrimination—insurance plans’ refusal to cover transition related services. In our recent review of insurance plan documents, we found that 92 health insurance issuers in 12 states excluded medically necessary transition related care. Such exclusions violate key protections in the ACA by denying coverage based on sex, gender identity, and health condition.
There is no medical reason why plans don’t cover transition related services. Major medical groups have identified transition related care as medically necessary. In fact, the majority of transition-related services are routinely covered for non-transgender people to treat other medical conditions. For example, patients with endocrine disorders as well as menopausal symptoms may use hormone therapy. And, transition related services can be added to insurance coverage without raising costs.
While insurance plans have been slow to comply with requirements that they cover transition related services, there is good news. In 2014, Medicare removed its transition related care exclusion. And at least nine states (Connecticut, Delaware, New Hampshire, New Jersey, Massachusetts, Maryland, Rhode Island, Vermont, and Washington [PDF]) and the District of Columbia explicitly prohibit public or private plans or both from excluding coverage for transition related services.