Tuesday, November 19, 2013

California Now Mandates Transgendered Services to be Covered in All Insured Contracts (Armstrong & Getty Show 11/19/13)

  • California joins Oregon and Colorado as the only three states in the U.S. to mandate all insurance premiums and contracts include coverage for transgender services. 
  • Covered services include sexual reassignment surgery and mastectomy with chest reconstruction, in addition to mental health and hormone therapy services.
  • This was not done via the state legislative process.  Instead, it was a regulatory action taken by two state agencies, the Department of Managed Healthcare and the Department of Insurance in their efforts to re-interpret anti-discrimination legislation passed in 2005. 
  • The mandate does not apply to self-funded plans but is loaded into the rates for fully insured contracts renewing in 2014 and later.  


This is not due to ObamaCare; it is solely for California and Oregon (Colorado had already done so).

Here is the exact language one carrier is using:
Transgender services
Due to regulatory developments in California, transgender services are now being covered in all ... California ... plans. This change is effective immediately and will be included in our 2014 renewals.  Covered services include sexual reassignment surgery and mastectomy with chest reconstruction, in addition to mental health and hormone therapy services. Cost sharing is the same as cost sharing for other medical services for the employer group’s plan (e.g., inpatient hospital cost sharing, office visit cost sharing, etc). A load for these benefits will be included in your rate build-up report with your renewal. [Emphasis added.]  
Here is how the coverage addition appears in the footnotes of one insurer's renewal package:

California Regulations issued on April 9, 2013 require all PPOs and HMOs to offer this coverage.  

The below article is from KATU in Oregon. It article is from January, 2013. But the regulations in California were subsequently updated to include all plans in the state.  The below article spoke only of coverage PPOs (not HMOs).   I've redacted the sections that don't make sense due to that change in California:
SALEM, Ore. (AP) — Regulators in Oregon and California have quietly directed ... health insurance companies to stop denying coverage for transgender patients because of their gender identity.

The states aren't requiring coverage of specific medical treatments. But they told ... private insurance companies they must pay for a transgender person's hormone therapy, breast reduction, cancer screening or any other procedure deemed medically necessary if they cover it for patients who aren't transgender. ...

Advocacy groups said the action is a major step forward in their long battle to win better health care coverage for transgender Americans.

"It's just a matter of fairness," said Ray Crider, a 28-year-old transgender man from Portland. "I just never felt that I was like anybody else. I see everybody else being taken care of without having to fight the system."

Officials in both states said the new regulations aren't new policies but merely a clarification of anti-discrimination laws passed in California in 2005 and in Oregon two years later.

Many health insurance policies broadly exclude coverage of gender identity disorder or classify it as a pre-existing condition. Transgender patients are often denied coverage for medical procedures unrelated to a gender transition, advocacy groups said, because insurance companies deem the condition to be related to their sex reassignment.

Some transgender patients also have trouble getting access to gender-specific care. A person who identifies as a man might be denied coverage for ovarian cancer screening or a hysterectomy. A transgender woman might be denied a prostate screening.

The state insurance regulators said those procedures, if covered for anybody, must be covered for all patients regardless of their gender.

Masen Davis, director of the Transgender Law Center in San Francisco, said he's unaware of insurance regulators in any other state taking similar action....

The Oregon Insurance Division issued its guidance last month in the form of a bulletin to insurers....

"This is a very historic bulletin, and it really indicates that the tide is turning on this issue," said Tash Shatz, transgender justice program manager at Basic Rights Oregon, an advocacy group.

Transgender advocates say gender reassignment, through hormone treatment or surgery, is medically necessary, and they've long fought insurance companies that argue the procedures are cosmetic. They hope the new state regulations will mean fewer procedures are refused and make it easier to appeal a denial.

The transgender community has picked up significant momentum securing health coverage in recent years. San Francisco in 2001 became the first U.S. city to cover sex reassignment surgeries for government employees. Seattle, Portland, Ore. and Berkeley Calif., have followed suit....

State regulators don't have authority to force insurance companies to cover specific procedures, like hormone therapy or genital reconstruction. But they've told insurers that if they provide breast reduction for patients with back pain, they can't deny it for a gender reassignment that's been deemed medically necessary. Insurers could unilaterally exclude coverage of, say, breast implants, but it would have to apply to all policyholders equally, including breast-cancer patients....

When Ray Crider heard the news, he danced around his apartment with his wife. A 28-year-old transgender man living in Portland, Crider fought a long battle to convince a previous employer to include transgender services in his policy.

Although he was insured, Crider paid thousands of dollars out of his pocket for testosterone treatment and mental health care before winning his fight for coverage of gender identity. He finally got a double mastectomy, covered by insurance, a year ago, he said, but not before the binder he used to flatten his chest required several emergency room trips because it constricted his breathing.

"This was one of the most incredible things that could ever happen," Crider said, "to know that there's a state full of people who won't have to go through what I went through."...
Also note that this can and does include children and youth. The availability of the procedure is to be determined by a doctor's designation of medical necessity.

The determination of "medical necessity" is, as you can imagine, not something that can always be proven by an MRI, X-Ray or visual diagnosis. Significant discretion is afforded to a physician or psychologist's determination of the physical, mental and emotional needs for such services.  As reported in a 1999 study on Medical Necessity by The California Healthcare Foundation and Stanford's Center for Health Policy
The most common and problematic medical necessity issues are decisions about durable medical equipment, elective surgery, and experimental/investigational treatments. ... Only a physician can make a denial (this is an accreditation standard of the National Committee for Quality Assurance (NCQA) as well as a requirement in the Knox Keene law in California); this fact is little known.  The number of denials is relatively small (on average, less than 8% of all documented requests are denied).  
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