The transgender community is a population whose voice has been a growing presence in America over the past few decades. Though transgender people have faced much adversity in gaining the proper respect, equality and the rights they deserve as all citizens do, strides have been made in several areas of law, including health insurance and health care. Because some individuals may have unique and specific health needs during times of transition, it is especially important to know whether certain medical procedures will be covered by insurance or not.
It is also essential to realize that anyone who does not identify with the gender to which they were assigned at birth cannot be declined a health insurance policy. As this would be a clear representation of discriminatory behavior, the work accomplished by those who have spoken out has made a moderate mark on health insurance law. The Affordable Care Act addressed one facet of this predicament by making sex discrimination in health insurance programs, hospitals and other medical facilities illegal — but only those that receive some amount of federal financing. State and local nondiscrimination laws hold private organizations accountable for acceptance and equality.
Protections in Health Insurance
A variety of health care and health insurance laws have been established to prevent discrimination, and penalize those who violate the rights of policyholders. The health care reform law has raised the bar for patient protections by creating The Patient’s Bill of Rights. This document puts an end to unjust actions among insurers, such as the decline of coverage based on a person’s health problems or lack of gender conformity. The following are few provisions from the ACA that help people get the coverage they need.
- Elimination of coverage denials: The ACA makes it possible for anyone to apply for health insurance and receive coverage the care they need, regardless of which gender they may be. Limiting coverage for any reason is unlawful if the decision is based on being transgender or due to the gender under which a person enrolled in the plan. For instance, it may be prosecutable for an individual under a plan receiving any federal funding to deny coverage for a prostate screening for a trans woman or a pelvic exam for a trans man if these services are otherwise covered.
- Pre-existing condition acceptance: As of January 1, 2014, insurers are no longer able to deny a person coverage based on having what an insurance company considers a pre-existing condition, which has included being transgender. You can now apply with any health plan and not be deemed ineligible or rated up for coverage simply because you require medical care. When the law passed in 2010, individuals under the age of 19 were immediately able to receive coverage without discrimination for pre-existing conditions. From 2011-2013, adults age 19 and older were able to use the Pre-Existing Condition Insurance Plan (PCIP) if they were turned down by insurers.
- Plan cancellations are illegal: Rescissions were a way for health insurers to cancel coverage once a person’s health changes, because of being transgender, or due to errors or omissions on a health insurance application. The ACA has established rescissions as an illegal procedure, unless the policyholder is committing fraud or intentional misrepresentation.
Coverage for Transitions
As with the majority of medical services, coverage varies from one health insurance company, state, and specific health plan to another. It cannot be assumed that one carrier, plan, or state is consistent with their coverage, therefore it is essential to read your specific plan’s details and outline of benefits, as well as the exclusions and limitations portion of your plan information. It is likely to be found under “transsexual surgery and related services.” If any details are missing, call your insurer and ask someone about specific types of coverage. Even if it is not included in your plan booklet, they are required to tell you the facts about your plan according to their official documents.
Many have experienced that getting coverage for sexual reassignment surgery (SRS) or hormone replacement therapy (HRT) is difficult, if not rare. Always make sure there you have full knowledge of your plan prior to making any decisions. Even if a health plan does not cover HRT or SRS, keeping yourself healthy throughout the process is crucial, and you will certainly want coverage for maintaining your health in the midst of drastic changes. Though a plan may not cover your surgery, the services it does cover will contribute greatly to the financial planning of your transition.
The Art of Getting Coverage
It seems one has to get a bit creative to get certain therapies covered. HRT can usually be covered by health insurance if the medical need is defined as a “hormone imbalance.” Even on health plans that have specific exclusions on trans-related services, prescriptions have been no issue to cover and can go by undetected. Once a person has reached a postoperative stage, hormones should be covered without any issues. Mental health care may be more easy to come by, as having depression should fit the bill for seeking psychological services. It is also an essential health benefit under health reform, meaning that plans on the exchange in every state will always include mental health coverage.
Surgeries, whether SRS or facial plastic surgery, are more difficult to get covered. As all surgery is very costly, insurance companies will carefully examine whether a surgery is “medically necessary” prior to authorizing coverage. At times, doctors who call a procedure medically necessary cannot persuade insurers to approve a service. This also varies between carriers, plans, and states. However, certain procedures may be deemed necessary if they are included in a more serious health condition or circumstance. To be more specific, a rhinoplasty may be covered if a person has trouble breathing or has been injured in a car accident. (Please do not deploy an airbag for the sake of getting surgery covered, it may be a bit more expensive in the long run.)
SRS is the most difficult to get coverage for, as many health plans make an effort to exclude the procedure specifically. There are some insurers who require a patient to be evaluated in front of a board of in-network doctors before approval, while others require you to pay out-of-pocket and provide later reimbursement. Some individuals have been able to get their SRS covered by certain health plans. According to a Minneapolis resident, Medica has paid for multiple SRS operations in full. The carrier apparently was confronted by a lawyer regarding denial of coverage for this procedure many years ago, and they have since added it as a fully covered benefit to avoid further repercussions.
Planning for the Future
Many individuals have also found it worthwhile to get an attorney behind them to hold the insurance company accountable. Also, it helps to implement a plan for saving up medical funds. A Health Savings Account (HSA) is a very common plan type that helps individuals do just that, save up tax-free dollars for use on medical expenses alone. Typically you must use the funds in the account within the calendar year, and it is also separate from your health plan, so you can bring the savings account with you even if you change plans.
Under health reform, there might not be quite as much tact involved with getting coverage for these operations, as they may be deemed medically necessary — yet nowhere in the law does it explicitly state transgender surgery is covered, or else we would have heard about that. It should not have to take legal action to persuade insurers that a surgery will cost them less than a class action lawsuit, but you might have to anyway. The Affordable Care Act changes much of the limiting and discriminatory elements regarding health insurance, however, the law doesn’t state that every service has to be covered just because you are now insurable. Keep the law firm’s number on hand and enroll in a health plan, now that you have the right to do so.
Apply for for Individual Health Insurance
Call us for a State Health Exchange Plan Quote at 888 803 5917
1. National Center for Transgender Equality. “Health Care Rights for Transgender People”. PDF.
2. Transsexual Road Map. “Transition and Insurance”. http://www.tsroadmap.com/reality/insurance.html.