Every morning, Sion Jesse gets up and tightly wraps cloth around his chest.
It has been 12 years since he transitioned from being a woman, but he can't afford a mastectomy. His insurance won't cover the surgery, despite his doctor deeming the procedure medically necessary because of Jesse's diagnosis of gender dysphoria.
And even though health plans will soon be prohibited from denying medically necessary services related to gender transition, insurers warn that coverage won't come fast or easy.
Previously, laws enforced by HHS' Office for Civil Rights were based on race, color, national origin, disability and age. This summer, the Obama administration proposed that those protections also block discrimination based on sex, including gender identity. The rules apply to any provider, plan or program that accepts federal dollars and carries out the anti-bias provisions of the Affordable Care Act.
Staff attorneys at the Tennessee Justice Center, a public interest law firm, said in a letter that many plans, including state Medicaid programs that restrict coverage based on gender, use categorical exclusions to deny assistance to individuals who do not identify with their biological sex. Plans, however, said they are struggling to adapt and are leaning on the CMS for guidance.
For instance, the proposed rule says transgender people should be able to identify their preferred gender on Medicaid or private coverage applications.
But most enrollment and claims systems simply document whether an individual is female or male and don't log more nuanced information about gender identity, which can cause problems. For example, a transgender woman might mark female on an enrollment application, but later seek services for men, such as a prostate exam.
A subsequent denial “may occur through no fault of the health plan or individual seeking coverage,” Jeff Myers, CEO of the trade group Medicaid Health Plans of America, said in a comment letter. Non-compliance could lead to fines or loss of Medicaid and Medicare funds.
Cigna Corp. supports the rule but has requested more time to make the changes. “We are concerned that the removal of a gender identifier could create an increase in abusive billing as well as adversely impact marketing efforts for wellness reminders, such as for mammograms,” David Schwartz, head of global policy at the plan, said in a letter.
Schwartz added that even though Cigna acknowledges that gender goes beyond biology, “biology remains relevant, particularly because not all gender-transition treatments, especially surgery, are required or pursued.” The rule stops short of demanding insurers that cover gender transition treatments such as surgery.
But advocates say plans must change their practices to properly serve a population susceptible to high rates of mental and behavioral health problems, suicide attempts, HIV infection, abuse and violence.
