Insurance professionals are still awaiting a final rule on nondiscrimination protections, including for transgender people, which the U.S. Department of Health and Human Services proposed in the fall for the Affordable Care Act.
“Because it hasn’t been finalized, we were getting questions from insurance companies about how it would apply to them,” said Pennsylvania Insurance Commissioner Teresa Miller.
The state Insurance Department decided to clarify how the proposed rule, called Section 1557, would apply in Pennsylvania by issuing guidance April 27 stipulating that policies cannot contain “a blanket exclusion of coverage for health services related to an individual’s gender transition.”
On the heels of Gov. Tom Wolf’s LGBT nondiscrimination orders, Miller said, “We thought, what a perfect opportunity to make it clear to insurance companies.”
“We were just really proud to make this happen,” she added.
Pennsylvania is the 17th state to issue this kind of guidance, said Thomas Ude, legal and public policy director with the Mazzoni Center. He said he’s more commonly seen policies that have blanket exclusions on care for gender dysphoria versus exclusions for certain procedures.
“This moves the discussion forward to a conversation on medical necessity,” Ude said, noting Mazzoni works with “a significant number” of people who want help navigating their insurance policies to receive coverage for gender care.
Miller said the Insurance Department would be scrutinizing the “medically necessary” criteria put out by insurers under its jurisdiction to make sure there aren’t barriers to care.
The Insurance Department regulates the commercial private market, not the self-insured, Miller said. She added people should check with their employers to find out if they have a Group and Pension Administrators plan, called a GPA. Some insurance cards through GPA plans have insurance company names on them, but they are not regulated by the Insurance Department.
The trans-inclusive guidance does not require insurers to cover any new services, but it does require policies to provide coverage for medically necessary services regardless of a person’s gender identity.
When asked about the recent lawsuit filed by a Delaware County trans man seeking Medicaid coverage for a hysterectomy, Miller said, “When you get into the nitty gritty of specific examples, that’s where it gets hairy. In many cases, it’ll be a case-by-case evaluation. It’s going to depend on the particular services covered in an individual’s plan.”
Ude agreed with that sentiment. But he went on to give the example that if a cisgender woman can receive coverage for hormone replacement therapy after breast cancer treatment, a transgender patient should also receive coverage for hormone replacement therapy.
“It’s incredible the insurance industry has begun to realize that providing coverage for gender confirmation care is cost efficient and benefits the overall health of people experiencing gender dysphoria,” Ude said. “The long-term goal is people won’t need to call us because they’ll get approval for the treatment they need without fighting for it.”