Obtaining coverage for transgender and gender-expansive youth
Transgender and gender-expansive youth face many barriers to health care. (Gender-expansive youth are defined as “youth who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience.”) Although some of these youth may be fortunate to have a supportive family and access to health care providers proficient in transgender health care, they still face difficulties in having their insurance cover transgender-related services. This is not an impossible task, but it is a constant struggle for many clinicians.
In this column, I will provide some tips and strategies to help clinicians get insurance companies to cover these critical services. However, keep in mind that there is no one-size-fits-all approach to obtaining insurance coverage. In addition, growing uncertainty over the repeal of the Affordable Care Act (ACA) – which was critical in lifting many of the barriers to insurance coverage for transgender individuals – will make this task challenging.
Health insurance is extraordinarily complex. There are multiple private and public plans that vary in the services they cover. This variation is state dependent. And even within states, there is additional variability. Most health insurance plans are purchased by employers, and employers have a choice of what can be covered in their health plans. So even though an insurance company may state that it covers transgender-related services, the patient’s employer may pay for a plan that doesn’t cover such services. The only way to be sure whether a patient’s insurance will cover transgender-related services or not is to contact the insurance provider directly, but with extremely busy schedules and heavy patient loads, this is easier said than done. It would be helpful to have a social worker perform this task, but even having a social worker can be a luxury for some clinics.
The ACA made it easier for transgender individuals to obtain insurance coverage. Three years ago, the U.S. Department of Health and Human Services stated that Medicare’s longstanding exclusion of “transsexual surgical procedures” was no longer valid.1 Although it did not universally ban transgender exclusion policies, it did allow individual states to do so. Thirteen states have explicit policies that ban exclusions of transgender-related services in both private insurance and in Medicaid, and an additional five states have some policies that discourage such practices.2 This allowed some insurance providers and state Medicaid plans to offer coverage of transgender-related services.
Another challenge in obtaining insurance coverage for transgender and gender-expansive youth is claims denial for sex-specific procedures. For example, if a transwoman is designated as “male” in the electronic medical record and requires a breast ultrasound, the insurance company may automatically reject this claim because this procedure is covered for bodies designated as “female.” If the patient’s insurance plan covers transgender-related services, the clinic can notify the insurance company that the patient is transgender; if the patient’s plan does not, then the clinic will need to appeal to the insurance provider. Alternatively, for clinics associated with federally-funded institutions (e.g., most hospitals), the clinician can use Condition Code 45 in the billing to override the sex mismatch, although not all hospitals have implemented this code.3
1. Patient’s identifying information. Usually the patient’s name and date of birth is sufficient. Clinicians should use the patient’s preferred name in the letter, but provide the insurance or legal name of the patient so that the insurance provider can locate the patient’s records.
2. Result of a psychosocial evaluation and diagnosis (if any). Many insurance providers are looking specifically for the gender dysphoria diagnosis.
3. The duration of the referring health professional’s relationship with the patient, which includes the type of evaluation and therapy or counseling (e.g., cognitive behavior therapy or gender coaching).
4. An explanation that the criteria (usually from the World Professional Association for Transgender Health standard of care4 or the Endocrine Society Guidelines titled Endocrine Treatment of Transsexual Persons5) for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy.
5. A statement that informed consent has been obtained from the patient (or parental permission if the patient is younger than 18 years).
6. A statement that the referring health professional is available for coordination of care.
