Transgender people face two prominent hurdles to equitable health care: coverage of procedures related to their actual gender transition (hormones, surgery, etc.) and coverage of sex-specific procedures that are as important for transgender people as for others, like mammograms, prostate exams, and cervical Pap tests. New guidance issued this week from the Departments of Health and Human Services, Labor, and the Treasury affirms that insurance companies must provide the services in this second category without discriminating on the basis of gender identity.
When a doctor or other health care provider determines that an exam is medically appropriate for a patient, the guidance instructs, “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.” A talking point memo accompanying the guidance offers, “This means, for example, that a transgender man with an intact cervix can get coverage without cost sharing for a pap smear, if recommended by his provider.”
The transgender guidance, couched in guidance about providing contraception to women, could make a profound difference for transgender individuals who have struggled to obtain the preventive medical care they need. It will protect people like Beth Scott and Jennifer Blair, who had to pay out-of-pocket for a mammogram and then go to court to have the costs reimbursed. In cases like theirs, coverage is often denied simply because of how gender is designated on their insurance ID cards.
In the 2011 National Transgender Discrimination Survey, a full 50 percent of respondents reported that they had postponed pursuing preventive care services because they could not afford it. This included a transgender man who was told by Blue Cross of California, “Unfortunately we are unable to process claims for one member under both genders,” and thus he could not be covered for procedures related to his anatomy. One 55-year-old transgender man was denied coverage for a bone density scan because according to the insurer’s policies, only women could qualify as “at-risk” for osteoporosis. Another transgender man sought treatment for an infection from an LGBT-friendly health provider; when he asked for additional preventive services, he was told that because his documents identify him as male, it wasn’t possible to submit a claim for a Pap test without compromising coverage for the other tests and treatments he received related to the infection.
This gender marker issue has created so many technical problems for trans people accessing the health care that they need that Medicare actually implemented an “override” code to correct the glitches. Since 2012, providers can note in the records that any conflict based on gender markers should be ignored, communicating that the service was not provided in error and allowing the claim to be processed without interruption.
The Affordable Care Act has great potential to end health care discrimination against transgender people, but gender markers have provided a kind of loophole for that discrimination to persist. Those whose income is low enough that they qualify for advanced premium tax credits must show the same gender marker on their health insurance policy as is associated with their social security card. As a result of this paperwork technicality, they have then been denied the sex-specific services prescribed by their doctors because the procedure doesn’t match their recorded gender.
Transgender people are increasingly finding enumerated protections in state health exchanges, but progress has been slow and uncertain. The new guidance will help them overcome the financial and procedural hurdles that have obstructed them from accessing the same preventive health services cisgender people regularly expect to be covered by their health care coverage.