More Employers To Cover Transgender Surgery, But New Hurdles Expected

The recently-released U.S. Department of Health and Human Services' "Healthy People" objectives for the next 10 years include a specific objective of recognizing transgender health needs as medically necessary.
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One year from now, more employers than ever before will cover transgender surgery as part of their health insurance plan. While this is much-needed progress for transgender people, implementation issues will unfortunately create new hurdles to living in one's true gender.

The coverage is a requirement in the 2012 Corporate Equality Index. An employer must contract for the coverage by June of this year and coverage must be effective January 1, 2012 in order to score 100 percent on the 2012 CEI.

This change will impact all transgender people even though many do not need or want surgery. That's because insurance company exclusions of transgender surgery, and in some cases any transgender care, have tended to make medical care providers regard anything transgender-related as frivolous.

The consequence of this is shocking. The recent National Transgender Discrimination Survey -- Report on Health and Health Care showed that 19 percent of the respondents of all ages were refused care because of their transgender or gender non-conforming status, 28 percent were subject to harassment in medical settings, and 2 percent were victims of violence in doctor's offices.

It's unclear if all 337 employers who scored 100 percent in the 2011 CEI survey will be able to arrange for the new coverage in time. The chief diversity officer of one employer told me that adding the coverage is his number one priority in 2011. Yet I'm guessing the change is big enough that some companies will fall from 100 percent in 2012.

While 85 of those employers already cover transgender surgery in some way, the challenge for all employers will be that the 2012 CEI requires coverage of surgery deemed medically necessary by the World Professional Association for Transgender Health (WPATH). It may take some employers longer than others to accept that procedures such as facial feminization surgery, usually dismissed as "cosmetic" in current coverage, should be covered.

For those employers large enough to "self-insure," conformance with WPATH requirements can easily be written into the health plan. But for other employers who must take the "plain vanilla" insurance offerings, many health insurers in the U.S. do not even offer a rider covering transgender surgery, and those who do typically impose requirements that differ from the WPATH requirements, usually in more restrictive ways.

One restriction in standard riders concerns the procedures involving breasts. For a person transitioning from female to male, a mastectomy is recognized by WPATH as the first step typically undertaken in a gender transition. For a male to female, WPATH sees breast enlargement as warranted after 18 months in cases where hormone therapy has not led to adequate breast tissue growth. But most standard insurance riders set an 18-month delay for any breast procedure, unacceptable for those transitioning to male.

Even with the most WPATH-compliant coverage, a significant hurdle will be that few of the current transgender surgery specialists accept insurance. In fact, most require prepayment of the full cost. Many employees are just not going to be able to come up with that kind of cash, and it's going to be a while before the market forces providers to accept insurance.

For those who can pay in advance, the insurance company's inexperience with transgender coverage could leave the employee hanging. In one company already providing coverage, a patient obtained the required pre-authorization letters from a therapist and the primary provider of care, received approval, and underwent surgery, only to find the insurance company refusing to pay because it decided after the fact that the employee's primary provider of care should have been a mental health provider. The patient is now scrambling to be pre-authorized after the fact.

Of course, most insurance companies limit payment to the "reasonable and customary" (R&C) amount for the particular surgery. Surprisingly, insurance companies already have these amounts determined since most transgender surgery procedures are actually the same procedures performed for non-trans people under different circumstances (for example, construction of a penis for a man who has been in a tragic accident). An employee could be caught short if the R&C amount ends up being less than trans surgery specialists normally charge.

And then there is a common requirement of using providers within the employee's home state. With so few surgeons specializing in transgender surgery, will this leave the employee with coverage, but no qualified surgeon? Or will it encourage the employee to gamble on a surgeon who has little experience with the procedure?

Regardless of the hurdles, the new coverage is timely. The recently-released U.S. Department of Health and Human Services' Healthy People objectives for the next 10 years include, for the first time, a specific objective of recognizing transgender health needs as medically necessary. The change in attitude brought by the new surgery coverage will go a long way toward achieving this objective.

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