Insurance Victory

An issue that has caused frustration, sadness, and exasperation (and that is just for me- imagine how my clients must feel!) is the issue of exclusions for transition-related services for transgender individuals. Most healthcare plans have specific exclusions for anything related to gender transition. This includes but is not limited to hormone blockers, hormones, and needed surgery for transgender individuals.  In my opinion, this is as outrageous as healthcare plans excluding other major medical conditions. These exclusions leave me feeling very helpless, as I can see so clearly what my clients need: medical transition. And I cannot provide this!

As important as being able to access medical transition is being able to access EARLY medical transition when clinically necessary. However, even with the support and assistance of their parents, many transgender youth run into roadblocks when trying to get hormone suppressors. They are outrageously expensive, and most health insurances have exclusions that state they will not pay for anything related to gender transition. (Can you imagine, being one of these preteens/teens who are right on the doorstep of getting the treatment they so desperately need to survive, but they cannot afford it?)

Such is the same for many of my transgender adult clients. Surgery is an important part of the transition for most of my adult transgender clients, and yet most insurances will not cover it. This is a major power problem for those who cannot afford to pay for such surgeries out-of-pocket. It is my opinion that they shouldn’t have to.

On April 9, 2013, a ground-breaking ruling was made on this issue:

“California’s Department of Managed Health Care (DMHC) has ordered California’s health plans to remove exclusions of coverage based on gender identity and expression…The newly issued DMHC letter instructs health plans to revise current plan documents to remove exclusions and limitations related to gender transition.  For transgender people, how and when they transition is typically a private decision made with their doctor. The American Medical Association, American Psychological Association, American Psychiatric Association, and the American Academy of Family Physicians have all deemed transition-related care to be medically necessary for transgender patients.” Read more about it here.

I am truly curious to see how this plays out with all of my clients, and hope it is in reality as good as it sounds! To progress!

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6 CommentsLeave a comment

  1. I love all of your posts, and this one is no exception. I am very happy withthe California decision and wish we could move our insurance regulators here in Washington State. I don’t think many cis gender people understand the effects of the insurance exclusions. Most insurers won’t even cover psychotherapy if it’s billed as “gender identity disorder”. The professionals who work with us have ways to lie around some of the exclusions. Female hormones are cheap, and E and T are widely available on the internet, but medical consultation and lab work are not cheap. Kids and adults self medicate, and have erroneous idea about dosing, figuring if one dose is good, more must be better, and wind up with liver failure, blood clots, etc, costing insurers much more than if they had covered the care properly. This is not to mention the kids who become self destructive when an unwanted puberty arrives.

    • Thank you for your thoughtful comment! I agree with you, and here’s to Washington soon following suit.

  2. Our foster trans daughter, who is still in Tanner One, doesn’t yet need blockers. But we can’t find out whether or not her insurance will cover it. Does anyone know if AHCCCS is covering blockers?

    • Hi Celeste,
      Do you reside in California? If yes, your insurance should cover it now. Have you called your insurance? If you are outside of CA, I have some ideas for how you can fight for it.

  3. Hello,
    I have a MTF 8 year old who does not need blocker’s yet, but will once puberty hits. We reside in CA but my employer’s health insurance is out of Florida. Any tips on what to do, how to handle? Should I call insurance to see if they’ll cover this when the time comes?

    • Hi Kelsey,
      In short, yes, I recommend calling and asking questions now. You can ask for a copy of the specific plan and have it faxed to you.
      I asked Matt Wood at the Transgender Law Center about your question. He said the long answer is that it “depends”. “If the employer is subject to CA state nondiscrimination law, than the employer’s insurance contract likely is as well. So if an employer was based in FL but had an office in LA they couldn’t get around CA employment nondiscrimination laws[…] Similarly, an employer with an office in LA with 50 employees can’t offer these employees an insurance policy that doesn’t comply with CA law, which prohibits blanket exclusions based upon gender identity. Keep in mind that it may depend upon whether the person is really an employee, and not a contractor, and on the company having a true residence in CA with a set number of employees, as opposed to someone who was working in an office in FL then moved to CA and now is working remotely from their home in LA. And a federal employee would be situated differently as well.”
      Hope this helps!

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