In­sur­ers say HHS rules pro­tect­ing trans­gen­der peo­ple pose chal­lenges

Modern Healthcare - - NEWS - By Vir­gil Dick­son

Ev­ery morn­ing, Sion Jesse gets up and tightly wraps cloth around his chest.

It has been 12 years since he tran­si­tioned from be­ing a woman, but he can’t af­ford a mas­tec­tomy. His in­sur­ance won’t cover the surgery, de­spite his doc­tor deem­ing the pro­ce­dure med­i­cally nec­es­sary be­cause of Jesse’s di­ag­no­sis of gen­der dys­pho­ria.

And even though health plans will soon be pro­hib­ited from deny­ing med­i­cally nec­es­sary ser­vices re­lated to gen­der tran­si­tion, in­sur­ers warn that cov­er­age won’t come fast or easy.

Pre­vi­ously, laws en­forced by HHS’ Of­fice for Civil Rights were based on race, color, na­tional ori­gin, dis­abil­ity and age. This sum­mer, the Obama ad­min­is­tra­tion pro­posed that those pro­tec­tions also block dis­crim­i­na­tion based on sex, in­clud­ing gen­der iden­tity. The rules ap­ply to any provider, plan or pro­gram that ac­cepts fed­eral dol­lars and car­ries out the anti-bias pro­vi­sions of the Af­ford­able Care Act.

Staff at­tor­neys at the Ten­nessee Jus­tice Cen­ter, a pub­lic in­ter­est law firm, said in a let­ter that many plans, in­clud­ing state Med­i­caid pro­grams that re­strict cov­er­age based on gen­der, use cat­e­gor­i­cal ex­clu­sions to deny as­sis­tance to in­di­vid­u­als who do not iden­tify with their bi­o­log­i­cal sex. Plans, how­ever, said they are strug­gling to adapt and are lean­ing on the CMS for guidance.

For in­stance, the pro­posed rule says trans­gen­der peo­ple should be able to iden­tify their pre­ferred gen­der on Med­i­caid or pri­vate cov­er­age ap­pli­ca­tions. But most en­roll­ment and claims sys­tems sim­ply doc­u­ment whether an in­di­vid­ual is fe­male or male and don’t log more nu­anced in­for­ma­tion about gen­der iden­tity, which can cause prob­lems. For ex­am­ple, a trans­gen­der woman might mark fe­male on an en­roll­ment ap­pli­ca­tion, but later seek ser­vices for men, such as a prostate exam.

A sub­se­quent de­nial “may oc­cur through no fault of the health plan or in­di­vid­ual seek­ing cov­er­age,” Jeff My­ers, pres­i­dent and CEO of the trade group Med­i­caid Health Plans of Amer­ica, said in a com­ment let­ter. Non­com­pli­ance could lead to fines or loss of Med­i­caid and Medi­care funds.

Cigna Corp. sup­ports the rule but has re­quested more time to make the changes. “We are con­cerned that the re­moval of a gen­der iden­ti­fier could cre­ate an in­crease in abu­sive billing as well as ad­versely im­pact mar­ket­ing ef­forts for well­ness re­minders, such as for mam­mo­grams,” David Schwartz, head of global pol­icy at the plan, said in a let­ter.

Schwartz added that even though Cigna ac­knowl­edges that gen­der goes be­yond bi­ol­ogy, “bi­ol­ogy re­mains rel­e­vant, par­tic­u­larly be­cause not all gen­der-tran­si­tion treat­ments, es­pe­cially surgery, are re­quired or pur­sued.” The rule stops short of de­mand­ing in­sur­ers that cover gen­der tran­si­tion treat­ments such as surgery.

But ad­vo­cates say plans must change their prac­tices to prop­erly serve a pop­u­la­tion sus­cep­ti­ble to high rates of men­tal and be­hav­ioral health prob­lems, sui­cide at­tempts, HIV in­fec­tion, abuse and violence.

Plans­they are said strug­gling to adapt, and are lean­ing on the CMS for guidance.

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