Helping the transgender community access healthcare

by Lisa Gillespie
Kaiser Health News

Despite the Affordable Care Act (ACA), some reports lean toward transgender people still fighting for access to crucial health services despite the ACA’s requirement that insurance companies not deny coverage based on gender or health history.

The issue stems from the fact that enrollees must check a single gender box when they sign up for a plan sold on the individual or small group markets, according to advocates and health care providers.

“What happens is that the health insurance companies have specific codes and they put you in as female or male; you only get services that go with that code,” said Robin Maril, senior legislative counsel at the Human Rights Campaign.

But someone who is transitioning from a woman to a man or vice versa might still have organs associated with the other gender, such as a uterus and breast tissue for someone born as a woman, or a prostate for someone born as a man. In addition, some transgender people forego reassignment surgery because of cost or other reasons.

As a result, they might still need annual mammograms or pap smears even if they are transitioning to men, or prostate exams if they are transitioning to women — not to mention treatment for problems typically regarded as gender-specific. They could range from sexually transmitted diseases to life-threatening illnesses such as cancer.

Before the healthcare law was passed, many insurance companies had exclusions barring transition-related care or care to transgender people in general, citing it as a “pre-existing condition.”

Under the federal health law, insurance companies selling policies in the individual or small group markets cannot deny coverage to transgender people or to those who are in the process of transitioning their sex. In addition, the administration released guidance in May telling insurers that they cannot deny coverage of sex-specific preventive services to transgender people. But advocates say that has not always happened in practice.

America’s Health Insurance Plans, a trade group, said that plans are complying with the law. “Health plans want to make sure patients have access to the care they need, and this latest guidance was aligned with those efforts. Plans do cover medically necessary care and preventive services for transgender individuals,” said Clare Krusing, of AHIP.

United HealthCare and Cigna did not respond to requests for comment. Kaiser Permanente said it has a process to address denials based on gender. Aetna said it has a process to cover these claims and is working to delink services from gender identification.

The challenges with insurers lead some transgender people to stick to their birth gender on their insurance ID cards.

Eli Strong started transitioning from female to male before passage of the Affordable Care Act, while he lived in Washington, D.C. and had employer-based coverage. In 2008, he changed all his legal identification to male, but kept his health insurance ID as female, because he had not yet gotten a hysterectomy. He didn’t want to have to fight his insurer over a gynecological exam.

Strong finally changed his insurance ID to male in 2014 after having a hysterectomy, but says, “What should determine my coverage is whatever organs I currently have, or conditions I am diagnosed with.”

The insurance industry argues the responsibility for clarifying health service needs should fall to the health care provider, arguing that the doctor can explain the patient is transgender in the notes section of a submitted claim. But that doesn’t always work because most insurance billing systems are automated and reproductive services like mammograms and prostate exams are flagged with a corresponding “female” or “male.”

Medicare already has codes that allow providers to identify the person getting, say, a pap smear or a mammogram, as transgender, which allows the claim to be processed. Transgender advocates and the AAPC, a trade group representing medical coders, say the same can be done with private insurers.

Advocates say their goal is to add new categories, such as ”transgender man,” or “transgender woman,” into insurance application forms, as well as into research, to get a more accurate picture of the number of transgender people, how many are denied coverage and how these denials affect health outcomes.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Gayly – August 9, 2015 @ 7:20am.