Transition services and health insurance coverage
Questions around health insurance coverage usually center on three components of medical care as part of a transition:
- medication (hormones/blockers)
Experiencing gender dysphoria — a fundamental "mismatch" between one's anatomical sex and the sex they know themselves to be —can be disorienting and, for some, traumatizing. Counseling can help address concerns transgender individuals may have, while also ruling out mental-health issues that can interfere with other aspects of treatment.
Medication for those who have already experienced puberty typically consists of prescribed hormones of the sex to which an individual is transitioning. For youth who have not yet experienced puberty, medication often consists of hormone-blockers, which delay the development of unwanted physical characteristics. There are some complex issues related to covering medications for minors experiencing gender dysphoria; insurance plans are inconsistent on this point.
Surgery can take many forms, including mastectomies and hysterectomies for transgender men, and the removal of male genitalia and construction of female genitalia for transgender women. Generally, surgery is only available for adults.
Insurance plans usually include a requirement, particularly regarding surgeries, that the services be considered “medically necessary.” Medical necessity is typically determined with reference to the Standards of Care developed by the World Professional Association for Transgender Health (WPATH). The Minnesota Department of Commerce, which has an external review process for insurance appeals, has ruled that insurers must use the WPATH standards, and may not substitute their own, more-restrictive standards.
Some health plans exclude coverage for these services altogether. On November 30, 2015, the Minnesota Departments of Commerce and Health issued an administrative bulletin confirming that health plans subject to their jurisdiction may not exclude coverage for these treatments when medically necessary. While this is a critical protection for transgender Minnesotans, it does not address the whole range of insurance issues trans people may face.
A major consideration for transgender people undergoing a transition is financial: what will insurance cover? The answers vary depending on the type of insurance:
Medical Assistance (MA)/Minnesota Care: Counseling is covered for adults and minors. Medication is covered for adults, and for the few minors who have already had gender-confirmation surgery. Surgeries are currently excluded for all as a matter of state law. However, due in part to regulations issued by the US Department of Health and Human Services in May 2016, this exclusion is expected to be unenforceable as of January 1, 2017; the Minnesota Department of Human Services has indicated it will consider surgical requests prior to that date on a case-by-case basis.
In November 2016, a Ramsey County judge declared the MA surgery ban unconstitutional. To read about the original lawsuit here.
MNsure: Private plans within MNsure are expected to cover counseling, hormones, and medically-necessary surgeries for adults; for minors, counseling and medications should be covered. However, MNsure plans based on MA or Minnesota Care currently follow the rule set out above. Need help figuring out MNsure? LGBTQ-sensitive MNsure navigators are available at the Minnesota AIDS Project; you do NOT need to be affected by HIV to call.
Medicare: In 2014, the US Department of Health and Human Services removed the exclusion from Medicare of coverage for gender-confirmation surgeries, so Medicare (including Part D) now covers the full range of transition services. More information, including information on appealing Medicare denials, is available here.
Employer plans: Employer plans tend to be all over the map. A key question is whether the employer’s plan is “fully-funded” or “self-insured”; this question may usually be answered by checking the plan document or with an employer’s human resources office. Fully-funded plans are generally subject to state law, and the Minnesota Department of Human Rights has concluded that health plans subject to state law may not arbitrarily exclude transition-related care. In contrast, larger employers (15+ employees) are often self-insured, and these plans are generally subject to federal law. Many believe that where such plans exclude coverage for transition care, they violate the Civil Rights Act of 1964. In at least one recent decision, the federal Equal Employment Opportunity Commission agreed.
Trans-Friendly Health Providers
Health providers that are trans-specific or -sensitive are challenging to find. The most useful provider directories we know of are available through the Minnesota Trans Health Coalition (MTHC) and the Rainbow Health Initiative (RHI) Search the RHI directory by selecting “Trans Issues” under the “Other Specialties and Sensitivities” drop-down menu. Some insurance companies provide similar search abilities in their network directory.
If you are a trans-sensitive health provider, you can increase access to healthcare for trans people by simply contacting these organizations to be included in their opt-in directories!