Transgender people access health care for all the same reasons anyone else does, but sometimes their transgender status is regarded by insurance carriers (and some care providers) as a barrier to care, even when that care is not related to a transition (i.e., reconstruction and alignment of sex characteristics from male to female, or from female to male, through the use of hormones and/or surgical interventions).
When a transition is in process, it may involve one or more types of medically necessary treatments. Most of these types of treatments are typically covered for other medical diagnoses, but many health insurance policies specifically exclude sex affirmation/reassignment-related treatments. The effective scope of those exclusions can vary significantly from one insurance plan to another.
Examining Your Plan's Exclusions
You must first find the insurance policy contract and examine the list of coverage exclusions or limitations for transgender-specific language. A complete list of exclusions will be found in the insurance contract, and partial lists are usually found in summary plan documents.
Confirming Availability of Inclusive Benefits
The absence of an explicit contractual exclusion does not guarantee that transition-related services will be considered medically necessary and covered. Further, contractual exclusions may not reflect current, actual implementation if the insurance administrator or relevant laws and regulations have changed to consider transition-related services as medically necessary and covered.
If you do not have language in your insurance contract that affirms availability of inclusive coverage, find a benefits manager experienced with the plan's exclusions and limitations to coverage for specific treatments and services. Work with this person to obtain an affirmative answer from your insurance administrator in response to the following question:
"Does our health plan cover the healthcare needs of transgender and transsexual individuals without exclusion as for any other individual, including routine, emergent or urgent care as well as services related to sex affirmation or reassignment? More specifically, do we have explicit exclusions in our insurance plan contract that specifically preclude such treatment and, if we do have such exclusions, are they still applicable?"
If the insurance representative tells you that your plan does not cover these services, here are other questions that might be helpful:
- Are you aware that many small and large businesses, including many Fortune 500 companies, have implemented such coverage for large self-insured plans and smaller fully-insured plans?
- Are you familiar with the World Professional Association for Transgender Health's Standards of Care (WPATH SOC), that defines the diagnosis process and medically necessary and appropriate treatment for individuals?
- Are you aware that the American Medical Association supports insurance coverage for this care?
- Are you aware that the U.S. Tax Court has determined that such treatments are considered medically necessary for tax purposes?
Confirming the Level of Inclusive Benefits
Some insurance plans cover a more limited set of services than others. To determine the level of inclusive benefits, you must examine (1) the range of services that will be covered and (2) the process under which these services will be covered.
Determining the range of services covered requires examining applicable clinical guidelines utilized by your insurance administrator, or an affirmative answer from your insurance administrator in response to the following question:
"Does our health plan cover the full range of medical procedures related to the process of sex affirmation or reassignment that are considered medically necessary by the current World Professional Association for Transgender Health Standards of Care (WPATH SOC v.6 2001 and WPATH Clarification on Medical Necessity 2008), when such treatment is medically indicated for the individual and is consistent with the WPATH SOC?"
Determining the process under which services will be covered requires examining applicable clinical guidelines utilized by your insurance administrator, or an affirmative answer from your insurance administrator in response to the following question:
"With regard to coverage determinations, does our health plan follow the current Standards of Care from the World Professional Association for Transgender Health (WPATH SOC) regarding sufficient documentation of clinical decisions and treatment plans? Specifically, diagnosis, assessment and treatment conforming to the current WPATH SOC v.6 2001, as appropriately documented by the treating provider(s) as per the WPATH SOC, will guide determinations of eligibility for a specific treatment, prior authorization/certification, and other utilization management decisions. Is this the case?"
Some insurance plans have implemented problematic documentation requirements that go far beyond the WPATH SOC requirements and can unnecessarily extend the timelines defined by the WPATH SOC.
An insurance administrator's clinical guidelines will generally not apply if your plan has transgender exclusions. Many insurance administrators maintain clinical guidelines or medical policy that indicate what treatments the plan considers medically necessary (e.g., reconstructive and not cosmetic) and conditions under which treatment will be covered -- these only apply to those plans without applicable exclusions.