US Gov: Health plans may not restrict preventive services for transgender people
Positive guidance issued yesterday by the US Department of Health and Human Services (HHS) told insurers that health insurance plans must cover preventive services for all consumers without co-pays or other out-of-pocket costs—regardless of gender. This means that preventive care can no longer be denied because someone is not the “right” gender for a service such as screening for breast or cervical cancer or sexually transmitted infections or contraception. This guidance will help many transgender consumers who have faced arbitrary barriers to needed preventive care—however, it does not address the larger, urgent problem of blanket transgender exclusions for transition-related surgeries in health plans.
Insurance companies have traditionally coded certain tests and procedures as being for either men or women, based on assumptions about body parts and gender. Insurance claims for services not deemed to “match” a person’s recorded gender are automatically denied, on the assumption that they represent an erroneous or fraudulent claim. While some plans have systems for health care providers to override these automatic rules, many patients have had to fight through the appeals process to get basic preventive care covered.
Yesterday’s guidance, in the form of Frequently Asked Questions, made clear that this is not allowed under the Affordable Care Act. The FAQ says:
“Whether a sex-specific recommended preventive service that is required to be covered without cost sharing under [the ACA] is medically appropriate for a particular individual is determined by the individual’s attending provider. Where an attending provider determines that a recommended preventive service is medically appropriate for the individual – such as, for example, providing a mammogram or pap smear for a transgender man who has residual breast tissue or an intact cervix – and the individual otherwise satisfies the criteria in the relevant recommendation or guideline as well as all other applicable coverage requirements, the plan or issuer must provide coverage for the recommended preventive service, without cost sharing, regardless of sex assigned at birth, gender identity, or gender of the individual otherwise recorded by the plan or issuer.”
The FAQ also addresses several other key areas of preventive care coverage where insurance companies have been slow in complying with the ACA. A recent report by the National Women’s Law Center found that many plans are still requiring co-pays for contraception despite the law’s preventive services requirements. The FAQ makes clear that plans must provide all forms of FDA-approved contraception without co-pays or other cost-sharing, and cannot cover only some forms of contraception (such as fully covering pills but requiring cost-sharing for the patch, ring, or intrauterine devices).
Also yesterday, the American College of Physicians joined other major medical associations stating: “The American College of Physicians recommends that public and private health benefit plans include comprehensive transgender health care services and provide all covered services to transgender persons as they would all other beneficiaries.” Unfortunately, the National Women’s Law Center recently reported that of health plans surveyed in a dozen states, 92 still contained broad transgender exclusions. These exclusions—which often deny services that are commonly covered for non-transgender consumers—also violate the ACA by discriminating on the basis of sex, gender identity, and health condition.
We urge anyone who is facing any form of discrimination by a health insurance plan to read NCTE’s health care Know Your Rights resource and consider filing a complaint with the HHS Office for Civil Rights.