How Being Transgender Affects Health Insurance Coverage

How Being Transgender Affects Health Insurance Coverage

How Being Transgender Affects Health Insurance Coverage

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Policy Scout

While the transgender community still suffers from health insurance discrimination, the Affordable Care Act has done much to improve the situation. According to the ACA, insurance companies that receive federal funding or have at least one plan on a federal or state healthcare marketplace may not discriminate based on gender identity or transgender status. That means that all the large healthcare companies must provide coverage for you. In most instances, you are entitled to the same healthcare services that other Americans enjoy. You do need to know which services are guaranteed under the law so you can protect your rights and choose the best policy for your circumstances.

Plan Enrollment

Marketplace health insurance companies cannot refuse to enroll you in a plan due to your transgender status. They may not cancel your coverage or charge you more for services either. They must treat you as they would any other member or potential member.

Preventative Care

The ACA requires that insurance companies provide preventative care without charging you either a copay or coinsurance. The law states that your insurance company may not deny you sex-specific recommended preventative services based on your gender at birth, your gender identity or recorded gender. That means that a transgender man who still has a cervix will receive a pap smear without being charged. In fact, when your doctor decides that a preventative service is medically necessary for you, it must be covered by your marketplace plan. That means finding a knowledgeable and understanding primary care physician and appropriate specialists is essential for you.

Transition-Related Care

Under the ACA, health insurance companies cannot automatically exclude you from transition-related care. A company cannot create a policy that simply denies all care if those denials are discriminatory. For instance, insurance companies usually cover hormone treatments for women in perimenopause or menopause. As a result, they cannot refuse to offer those treatments for those who wish to transition to the female gender. If a company covers breast reconstruction for cancer patients, it must offer the same service for transgender patients. If these companies are discriminatory in paying for these treatments, then you have legal recourse.

Healthcare Providers Who May Not Discriminate

Most healthcare providers cannot discriminate against transgender patients. Any healthcare provider who accepts federal funding, including Medicare or Medicaid, or is administered by a federal agency must provide treatment under the ACA. They include:

  • Hospitals

  • Doctors' offices

  • Nursing Homes

  • Medical residency programs

  • Veterans' health centers

  • Assisted living facilities

  • Community health clinics

  • Prison and detention facility health clinics

Rarely will you find a facility that does not accept federal funding. There are few places that would legally be able to deny you treatment.

Insurance Plans with Transgender Exclusions

Some insurance plans still have specific transgender exclusions that may or may not be legal. They may deny sex reassignment surgery or "services related to sex change." These coverage stipulations do vary state by state and policy by policy. Healthcare.gov warns that you need to read a plan's certificate of coverage, contract of insurance or evidence of coverage before you enroll. These sections will spell out what is covered and excluded in each plan. You should particularly look for terms like "gender identity disorder," " transsexualism," "gender identity disorder," etc. If you feel that a company's policy is discriminatory in any way, you should contact your state's department of insurance. You may also contact the Centers for Medicare & Medicaid Services.

Veterans Administration Coverage

Under the ACA, transgender veterans must be covered by the VA for most services, including medical services before and after the surgery. The VA does not cover the actual sex reassignment surgery at this point, however. The VA is actively considering changing its policy to include these surgeries for vets, although nothing has been decided at this point. While the VA does provide care for transgender vets, the military may not be able to include openly transgender troops in their ranks anymore due to a recent executive order by the president. Currently, this ban has been put on hold by the courts, but if it is allowed to be implemented, it may quash the movement to allow gender reassignment surgeries for vets. Before enrolling in any healthcare policy, everyone needs to understand what the policy covers and what it excludes. While the ACA has made certain coverages mandatory, some items are still up to the individual insurance companies. Transgender people are offered a number of protections under the ACA, but some companies still exclude certain procedures, in particular, the actual gender reassignment surgery. You do have recourse if you feel that you have been discriminated against by an insurance company. Your state's department of insurance is a good place to begin.

Conclusion

Smaller insurance companies who are not members of the government healthcare marketplace are not bound by the same coverage rules. However, if an insurance company receives any government funding at all, it must abide by the ACA. Healthcare facilities must also follow these rules. While a few insurance companies and medical facilities take no government money, they are few and far between. Know your healthcare rights and report any plan or provider who fails to give you the care you are due. Transgender patients do have a number of protections under the law.

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