Update On Medicaid Coverage Of Gender

Transgender and nonbinary adults often face challenges and barriers to accessing needed health services and face worse health outcomes than their cisgender peers. Transgender adults are more likely than cisgender adults to be uninsured, report poor health, have lower household incomes, and face barriers to care due to cost. Given their lower incomes, Medicaid plays an important role in health coverage for transgender people. A 2019 report by the Williams Institute estimated that among the 1.4 million transgender adults living in the United States, approximately 152,000 had Medicaid coverage.

Medicaid is the countrys health coverage program for low-income people and is jointly funded by the federal government and states. Under Medicaid, states must cover certain mandatory benefits, such as inpatient and outpatient services, home health services, and family planning services. While there are no specific federal requirements regarding coverage or exclusion of gender-affirming health care services as a category of Medicaid benefits, there are rules regarding comparability requiring that services must be equal in amount, duration, and scope for all beneficiaries within an eligibility group.

Does My Health Insurance Cover The Gender Affirming Care Of My Child/legal Dependent

• Most insurances that are based in California provide gender affirming care insurance coverage for clients who are younger than 18.
• Each insurance plans coverage varies, so contact your health insurance directly to see what gender affirming care services are a covered benefit.
• No gender affirming medical interventions can be made for children under the age of 18 without consent from parents/legal guardians.

Private And Public Insurance Reform

As of 2015, an increasing number of employers are offering transgender-inclusive health benefits plans, and insurance Commissioners in numerous states and the District of Columbia have issued regulations prohibiting the sale of insurance plans that discriminate against transgender people. Further, on May 30, 2014, the U.S. Department of Health and Human Services issued a ruling that Medicare’s longstanding exclusion of “transsexual surgical procedures” was no longer valid, leaving the provision of services up to local coverage determinations. Following suit, some states have begun to revise their Medicaid plans to offer transgender-inclusive health care. Specific Medicaid policies can be obtained from individual state Medicaid regulatory agencies. Currently the Center for Medicare and Medicaid Services is in the process of developing a new National Coverage Determination with regards to inclusion of gender affirming care in the Medicare program. Private health insurance products are often regulated by the State Department of Insurance or Department of Managed Care specific policies and coverage details can be obtained from individual state agencies.

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How To Get Your Gender Confirming Surgery Covered By Insurance

Some of the most stressful questions arise when trying to figure out insurance coverage for gender confirming surgery. Youre not alone if youre looking at your Google search history and see:

• Insurance companies that cover gender confirmation surgery
• Top surgery insurance
• Does insurance cover gender confirming surgery?
• Insurance that covers top surgery
• Whats the cost of top surgery?
• Is gender confirming surgery covered by insurance?
• How to get top surgery covered by insurance
• Top surgery grants
• Transgender surgery insurance coverage
• Best insurance for transgender coverage

Were here to provide some guidelines to help answer some of these questions. Your first step is to reach out to us for a consultation. We have an insurance concierge who works directly with your insurance provider to see what transgender medical insurance benefits you have.

Our insurance advocacy team will take you through every step of the insurance approval process until either approval is achieved or when it becomes clear that you do not have coverage. Because one of our main goals is to get your gender confirmation surgery covered by insurance, we provide the insurance advocacy work as a free service to all of our patients to give everyone the best chance of success.

Our team has experience securing insurance approvals for our surgeons to work with the following insurance providers:

• United Health Care

To help us verify the benefits, we will need the following information from you:

Recent Events Affecting Transgender Surgeries

Fast-moving currents of both positive and negative change are affecting individuals access to gender reassignment treatments. To a growing extent, health insurance companies and large employers are covering gender-altering surgeries. A Willis Towers Watson industry survey found that an increasing number of employers are taking action to add transgender medical benefits. In December 2020, a federal prisoner in Wisconsin won her lawsuit demanding sexual reassignment surgery. And in May 2021, the Utah Supreme Court affirmed the right of transgender people to change their sex designation on their birth certificate.

On the other hand, based on reporting by The New York Times, hundreds of bills restricting the rights of transgender people have been introduced across the U.S. Treating gender dysphoria in younger people is particularly controversial.

For example, in May 2021, Karolinska hospital in Stockholm, the first in Sweden to offer gender identity assessments for children, stopped giving hormone treatment. This happened after the hospital found the treatments were causing serious, sometimes irreversible, side effects such as cardiovascular disease, osteoporosis, infertility, cancer, and thrombosis.

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Insurance And The Wpath Standards

There are several different surgeries that people may be interested in for gender alignment or confirmation. In addition, there are often specific guidelines for coverage for each surgery.

As a general rule, many insurers are turning to the WPATH Standards of Care as guidelines to establish eligibility for surgery coverage. These are also known as the WPATH criteria or WPATH requirements.

WPATH is the acronym for the World Professional Association for Transgender Health. Originally known as the Harry Benjamin International Gender Dysphoria Association, WPATH is not without controversy.

What If I Am Treated With Disrespect

If you encounter disrespect, harassment or other discrimination or inappropriate treatment related to being transgender, you may make a complaint. For problems when making inquiries or appeals in a private Medicare Advantage or Part D plan, you may file a complaint or grievance with your plan. For any other customer service problems, we recommend contacting your regional Center for Medicare and Medicaid Services office. You can also with NCTE to aid in our advocacy efforts.

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Affordable Care Act Policies

Individuals can purchase their own health insurance policies, often with significant government subsidies, at healthcare.gov. Subsidies on policy premiums have been boosted as part of COVID-19 relief.

Under the Affordable Care Act, insurers cannot discriminate against individuals on the basis of gender identity, and most insurance companies provide coverage for people who require gender reassignment surgery. Still, policies vary by state and in what they cover, and many health plans still exclude services related to sex change or sex reassignment surgery. Check a policys complete terms of coverage for the full explanation of which procedures and services are covered or excluded under each plan. Many plans deny coverage to transgender people for certain healthcare services.

How Do I Change The Gender Marker With Medicare

Original Medicare beneficiary cards no longer list gender. Your Medicare insurance records will typically be based on Social Security data. To learn more about updating your name and gender marker with Social Security, check out our ID Documents center.

As a reminder, the gender marker you have in the Medicare record system should not impact access to care. Medicare should provide access to all clinically appropriate services for your body, including services typically considered to be âsex specificâ . The Medicare manual has a specific billing code to assist processing of claims under original Medicare . This billing code should be used by your physician or hospital when submitting billing claims for services where gender mis-matches may be a problem.

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What If I Do Not Have Health Insurance

• New potential UCLA Gender Health Program patients without active health insurance are strongly encouraged to seek coverage either through Covered California or through MediCal. Options vary by income level please see these services websites for more information.
• Covered California and MediCal have multiple plan options. Before making your selection, contact the insurance plan and ask whether UCLA Health Gender Health Program providers are in-network.
• MediCal will often assign you to an in-network primary care physician based on where you live. You can work with this doctor to get referrals to our medical and surgical services.
• If you select an HMO option through Covered California, you may choose a UCLA Gender Health Program provider to be your plan-assigned primary care physician. Once your insurance is active and your UCLA Gender Health Program primary care provider is confirmed, please submit an Appointment Request form.
• Some Planned Parenthood locations also provide low cost primary care and hormone replacement therapy services for folks who do not have health insurance.

Faq: Equal Access To Health Care

Gender dysphoria is a medical diagnosis defined by the Diagnostic and Statistical Manual of Mental Disorders , the American Psychiatric Associations handbook of official diagnoses, as he distress that may accompany the incongruence between ones experienced or expressed gender and ones assigned gender. The World Health Organization recognizes gender dysphoria as characterized by a persistent and intense distress about assigned sex together with a desire to be, or insistence that one is, of the other sex.

The American Medical Association established in a 2008 resolution that gender dysphoria is a serious medical condition with symptoms including distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death.

No they do not, because not every transgender person experiences the distress associated with gender dysphoria.

The treatment for gender dysphoria involves some combination of triadic therapy: hormone therapy, gender-affirming surgery and/or Real Life Experience . Each patient must be evaluated on a case-by-case basis, with expert medical judgment required for both reaching a diagnosis and determining treatment. There is no set formula for gender transition.

For people who are incarcerated, courts have called these sorts of blanket policies deliberate indifference and ruled that they violate the Eighth Amendment prohibition against cruel and unusual punishment.

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What Laws Protect Me

Federal protections

• The Health Care Rights Law, as part of the Affordable Care Act prohibits sex discrimination, including anti-transgender discrimination, by most health providers and insurance companies, as well as discrimination based on race, national origin, age, and disability. Under the ACA, it is illegal for most insurance companies to have exclusions of transition-related care, and it is illegal for most health providers to discriminate against transgender people, like by turning someone away or refusing to treat them according to their gender identity. On May 5th, 2021, the Biden Administration and HHS announced that the Office for Civil Rights will interpret and enforce Section 1557 and Title IXs prohibitions on discrimination based on sex to include:

Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in covered health programs or activities. The update was made in light of the U.S. Supreme Courts decision in Bostock v. Clayton County and subsequent court decisions. Now transgender people are encouraged to report any discrimination they experience while seeking health care services. The HHS has encouraged consumers who believed that a covered entity violated their civil rights may file a complaint at:

• Puerto Rico private insurance

Health Care For Transgender Older Adults

Transgender older adults can encounter challenges in the access and quality of care received in health care systems and nursing homes, where providers may be ill-prepared to provide culturally sensitive care to trans people. Trans individuals face the risk of aging with more limited support and in more stigmatizing environments than heteronormative individuals. Despite the rather negative picture portrayed by medical literature in relation to the depression and isolation that many transgender people encounter at earlier stages of life, some studies found testimonies of older LGBT adults relating feelings of inclusion, comfort and community support.

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Breaking Down The Costs

Candidates for gender reassignment surgeries are often required to live a year in their identified gender role and undergo at least a year of hormone treatments and perhaps permanent hair removal.

Hormone treatments involve estrogen for male-to-female patients and testosterone for female-to-male patients. Most patients will pursue hormone treatments, which are generally continued for the duration of the patients life. While these drugs are not usually especially expensive, they can add up to more than $2,000 a year.

Bottom surgery, or changing the genitalia, costs an estimated $25,600 for male-to-female patients and about $24,900 for female-to-male, according to The Philadelphia Center for Transgender Surgery. The center publishes a detailed price list of surgery and hospital anesthesia costs for common procedures, though costs may vary widely.

Top surgery involving breast augmentation for male-to-female transitions costs about $9,000. For female-to-male, top surgery involving mastectomy ranges from $7,800 to $10,900, depending on the amount of skin reduction. Masculinizing or feminizing facial surgery and body sculpting surgeries add to the costs.

What Is Gender Reassignment Surgery

Gender reassignment is also known as gender affirmation or confirmation surgery. According to the Cleveland Clinic, gender affirmation refers to the procedures that assist people in transitioning to their self-identified gender. This may include facial surgery and top or bottom surgery. People may pursue this surgery to match their physical body to gender identity, also known as gender dysphoria.

Gender identity refers to an individualâs own concept of male, female, a blend of both, or neither. According to the American Medical Association , approximately 1.4 million adults in the United States identify as transgender, but not all transgender people experience gender dysphoria.

We spoke with Dr. Kyle Zrenchik, who emphasizes that âthe diagnosis of Gender Dysphoria is a bit controversial. Many argue that it unfairly places the âpathologyâ on the patient, making it appear that it is their emotional distress that is the problem instead of their biology and being born into the wrong body. Many argue that the problem is better understood in our conceptualization of gender and sex and the ways that fail people who fall outside the binary.

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What Can I Do If I Face Discrimination

Seek preauthorization for care and appeal insurance denials

You shouldnt be denied the care that you need just because youre transgender. That’s illegal.

To access transition-related care, we recommend applying for preauthorization before any procedures to understand whether your plan will cover it. You should also consider appealing insurance denials that you believe are discriminatory. We recommend you consult an attorney before filing any appeals.

See these resources for more information about your rights during COVID-19:

Check our NCTEs Health Coverage Guide for more information on how to get the care that you need covered.

Contact an attorney or legal organization

If you face discrimination from a health care provider or insurance company, it may be against the law. You can talk to a lawyer or a legal organization to see what your options are. A lawyer might also be able to help you resolve your problem without a lawsuit, for example by contacting your health care provider to make sure they understand their legal obligations or filing a complaint with a professional board.

File discrimination complaints with state and federal agencies

Here are some other places you can file health care complaints:

Other state and local agencies: If you face discrimination, you may be able to file a complaint with your states human rights agency. You can find a list of state human rights agencies here: .

Plans Not Covered By New York Protections

• Individual Coverage You Buy Outside New York. If you buy individual coverage in another state, the rules of that other state will apply.
• Group Coverage Your Employer Buys Outside New York. If your employer buys a group insurance policy in another state , the policy may cover employees in New York, but New York protections dont apply.
• Self-Funded Group Coverage. If your employer self-funds the coverage, as many large employers do, an insurer may still process the claims, but New York protections dont apply.

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Note On Breast Reduction/mastectomy And Nipple Reconstruction

The CPT codes for mastectomy are for breast cancer, and are not appropriate to bill for reduction mammaplasty for female to male gender affirmation surgery. CPT 2020 states that Mastectomy procedures are performed either for treatment or prevention of breast cancer. CPT 2020 also states that “Code 19303 describes total removal of ipsilateral breast tissue with or without removal of skin and/or nipples , for treatment or prevention of breast cancer. There are important differences between a mastectomy for breast cancer and a mastectomy for gender reassignment. The former requires careful attention to removal of all breast tissue to reduce the risk of cancer. By contrast, careful removal of all breast tissue is not essential in mastectomy for gender reassignment. In mastectomy for gender reassignment, the nipple areola complex typically can be preserved.

Answers For Every Insurance Question

We know that finding the right care and understanding your benefits can seem overwhelming at times. Our Member Services team is always ready to help you understand your insurance coverage. Were available to you via phone, email or online chat. Our team members will answer your questions about benefits and coverage for gender services. If you want to know more about hormone therapy, transitioning and gender surgeries, we can help.

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Gender Affirming Surgery Mastectomy Hormone Therapy And Counseling Services

U-M Health Plans cover medically necessary genital surgery for gender affirming surgery, mastectomy in female-to-male transition, hormone therapy and counseling services. Applicable co-pays, deductibles and coinsurance are based on the member’s plan selection. There are no plan maximums for these services.