IntroductionIn the USA, it has long been the case that coverage for transgender health care has been specifically excluded, meaning indigent patients simply get nothing. There have been signs of a change in the past few years, with more and more employers adding coverage to their group plans, Medicare's exclusion of sex reassignment surgery being overturned, state regulators requiring coverage, and a proposed rule from the feds that may require coverage.
We've still got a long way to go, however, and for the past few years when it comes to coverage for sex reassignment surgery I've been on the outside looking in as none the plans I've been on have added coverage. Basically, the changes made so far do not seem to have reached me and blanket exclusions of transgender health care appear to remain common. It seems to still be common industry practice to exclude coverage of transgender health care.
There has been a lot of confusion, however, about the current status of coverage in this country. Some people think the feds have already outlawed these blanket exclusions, which is not true. Lots of people seem to think there is a "medical necessity" exception to these blanket exclusions, which is largely not true.
To rectify this confusion and to show the extent of the problem, I wanted to document all the health plans that are available to me for 2016 for these blanket exclusions of transgender health care on the healthcare.gov exchange, to help determine how things are on the ground. I live in Shelby County, TN, so I will reference all the plans available to me. Open enrollment is not until November 1, but on healthcare.gov plan previews for 2016 have already become available. I found 67 plans sold by a total of 4 health insurance companies, BlueCross BlueShield of Tennessee, Cigna Healthcare, Humana, and UnitedHealthcare. This is what I found.
BlueCross BlueShield of TennesseeThis is the coverage policy for gender reassignment:
Note this statement, which says gender reassignment may be excluded (all caps in original):
THIS GENDER REASSIGNMENT ADMINISTRATIVE POLICY ONLY APPLIES TO PLANS/POLICIES THAT EXPRESSLY COVER GENDER REASSIGNMENT. THIS ADMINISTRATIVE POLICY DOES NOT PERTAIN TO, NOR APPLY TO, ANY OTHER INSURANCE POLICIES OR HEALTH PLANS ISSUED BY BLUECROSS BLUESHIELD OF TENNESSEE, INC. THROUGH ANY OTHER MEANS, EITHER PUBLIC OR PRIVATE.I was able to find the full policies for the BCBST plans:
On p. 72 of all policies except the Multi-state policies, this exclusion can be found under "V. Reconstructive Surgery" -> "2. Exclusions":
c. Surgeries and related services to change gender (transgender Surgery) [sic].Interestingly, mental health care and hormones do not seem to be excluded, because of the way this policy is put under reconstructive surgery. I am currently on a BCBST plan and I've gotten psychotherapy and hormones covered even with the providers telling me they are billing GID/gender dysphoria.
On the Multi-state policies, the exact same exclusion can be found on p. 71 (which is specified). Here is a list of all plans, along with each plan's policy document:
Bronze B07E, Network E (Bronze PPO) Plan ID: 14002TN0330049
Bronze B02E, Network E (Bronze PPO) Plan ID: 14002TN0330044
Bronze B07S, Network S (Bronze PPO) Plan ID: 14002TN0330051
Bronze B02S, Network S (Bronze PPO) Plan ID: 14002TN0330041
Bronze B04E, Network E (Bronze PPO) Plan ID: 14002TN0330045
Bronze B01E, Network E (Bronze PPO) Plan ID: 14002TN0330043
Bronze B04S, Network S (Bronze PPO) Plan ID: 14002TN0330042
Silver S04E, Network E (Silver PPO) Plan ID: 14002TN0330013
Bronze B01S, Network S (Bronze PPO) Plan ID: 14002TN0330040
Silver S02E, Network E (Silver PPO) Plan ID: 14002TN0330012
Silver S09E, Network E (Silver PPO) Plan ID: 14002TN0330016
Silver S19E, Network E (Silver PPO) Plan ID: 14002TN0330031
Silver S16E, Network E (Silver PPO) Plan ID: 14002TN0330020
Bronze B04P, Network P, a Multi-State Plan (Bronze PPO) Plan ID: 14002TN0330034
http://www.bcbst.com/sbc/2016/127600/B04P_Policy.pdf (exclusion on p. 71)
Silver S04S, Network S (Silver PPO) Plan ID: 14002TN0330003
Silver S08E, Network E (Silver PPO) Plan ID: 14002TN0330015
Silver S02S, Network S (Silver PPO) Plan ID: 14002TN0330002
Silver S09S, Network S (Silver PPO) Plan ID: 14002TN0330006
Silver S19S, Network S (Silver PPO) Plan ID: 14002TN0330033
Silver S01E, Network E (Silver PPO) Plan ID: 14002TN0330011
Silver S11E, Network E (Silver PPO) Plan ID: 14002TN0330017
Silver S12E, Network E (Silver PPO) Plan ID: 14002TN0330018
Silver S16S, Network S (Silver PPO) Plan ID: 14002TN0330010
Silver S14E, Network E (Silver PPO) Plan ID: 14002TN0330019
Silver S08S, Network S (Silver PPO) Plan ID: 14002TN0330005
Silver S09P, Network P, a Multi-State Plan (Silver PPO) Plan ID: 14002TN0330035
http://www.bcbst.com/sbc/2016/127600/S09P_Policy.pdf (exclusion on p. 71)
Silver S01S, Network S (Silver PPO) Plan ID: 14002TN0330001
Silver S11S, Network S (Silver PPO) Plan ID: 14002TN0330007
Silver S12S, Network S (Silver PPO) Plan ID: 14002TN0330008
Silver S14S, Network S (Silver PPO) Plan ID: 14002TN0330009
Gold G10E, Network E (Gold PPO) Plan ID: 14002TN0330060
Silver S11P, Network P, a Multi-State Plan (Silver PPO) Plan ID: 14002TN0330036
http://www.bcbst.com/sbc/2016/127600/S11P_Policy.pdf (exclusion on p. 71)
Silver S12P, Network P, a Multi-State Plan (Silver PPO) Plan ID: 14002TN0330037
http://www.bcbst.com/sbc/2016/127600/S12P_Policy.pdf (exclusion on p.71)
Gold G08E, Network E (Gold PPO) Plan ID: 14002TN0330059
Gold G01E, Network E (Gold PPO) Plan ID: 14002TN0330057
Gold G10S, Network S (Gold PPO) Plan ID: 14002TN0330055
Gold G11E, Network E (Gold PPO) Plan ID: 14002TN0330061
Gold G08S, Network S (Gold PPO) Plan ID: 14002TN0330054
Gold G06E, Network E (Gold PPO) Plan ID: 14002TN0330058
Gold G01S, Network S (Gold PPO) Plan ID: 14002TN0330052
Gold G11S, Network S (Gold PPO) Plan ID: 14002TN0330056
Gold G08P, Network P, a Multi-State Plan (Gold PPO) Plan ID: 14002TN0330038
http://www.bcbst.com/sbc/2016/127600/G08P_Policy.pdf (exclusion on p. 71)
Gold G06S, Network S (Gold PPO) Plan ID: 14002TN0330053
Platinum P01E, Network E (Platinum PPO) Plan ID: 14002TN0330070
Platinum P02E, Network E (Platinum PPO) Plan ID: 14002TN0330071
Gold G11P, Network P, a Multi-State Plan (Gold PPO) Plan ID: 14002TN0330039
http://www.bcbst.com/sbc/2016/127600/G11P_Policy.pdf (exclusion on p. 71)
Platinum P03E, Network E (Platinum PPO) Plan ID: 14002TN0330072
Platinum P01S, Network S (Platinum PPO) Plan ID: 14002TN0330067
Platinum P02S, Network S (Platinum PPO) Plan ID: 14002TN0330068
Platinum P03S, Network S (Platinum PPO) Plan ID: 14002TN0330069
Cigna HealthcareHere is Cigna's coverage policy for gender reassignment surgery:
Naturally, this statement is found in the policy, informing the reader that there may be plans that exclude gender reassignment surgery:
For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document.On p. 7 of the plan brochures, under "2016 PLAN EXCLUSIONS AND LIMITATIONS" (emphases in original):
Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex, including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.This exclusion was found for all of the plans on the exchange. Here are all the plans and their plan brochures (with the exclusion on p. 7):
Cigna Health Savings 6000 (Bronze PPO) Plan ID: 99248TN0020001
Cigna Health Flex 6400 (Bronze PPO) Plan ID: 99248TN0020002
Cigna Health Savings 2700 (Silver PPO) Plan ID: 99248TN0020003
Cigna Health Flex 4000 (Silver PPO) Plan ID: 99248TN0020005
Cigna Health Flex 2250 (Silver PPO) Plan ID: 99248TN0020004
Cigna Health Flex 1200 (Gold PPO) Plan ID: 99248TN0020007
HumanaI could not find a coverage policy for Humana.
The exclusion is under "Limitations and exclusions (things that are not covered)" -> "Pregnancy and sexuality services" on p. 7 of the plan brochures:
Sex change services and sexual dysfunction.Here are all the plans with the plan brochures:
Humana Bronze 6450/Memphis PPOx (Bronze PPO) Plan ID: 82120TN0600022
Humana Silver 3800/Memphis PPOx (Silver PPO) Plan ID: 82120TN0600023
Humana Gold 2250/Memphis PPOx (Gold PPO) Plan ID: 82120TN0600024
UnitedHealthcareHere is the coverage policy for gender dysphoria:
Again, this sort of statement appears, saying that transgender health care may be excluded:
In the event of a conflict, the enrollee's specific benefit document supersedes these guidelines.I could not find the exclusion in the plan brochures, but on p. 12 of the plan brochures, it says that the list is not complete, directing the reader to this link, which contains sample medical policies for individual and family plans in each state:
I selected Tennessee:
I found the exclusion under "Section 2: Exclusions and Limitations" -> "M. Procedures and Treatments" on p. 31:
Sex transformation operations and other services.It was not clear whether this Compass Plus Policy for Tennessee applied to 2015 or 2016, so I called UnitedHealthcare up. They said that the information about 2016 will be updated this Sunday, November 1, when next year's enrollment begins.
Here is the plan brochure which is used by all the plans:
Here is a list of all the plans sold by UnitedHealthcare on the healthcare.gov exchange for me in Shelby County, TN:
Bronze Compass 4200 (Bronze POS) Plan ID: 69443TN0070008
Bronze Compass HSA 5200 (Bronze POS) Plan ID: 69443TN0070006
Bronze Compass 6400 (Bronze POS) Plan ID: 69443TN0070007
Silver Compass 5000 (Silver POS) Plan ID: 69443TN0070005
Silver Compass HSA 3600 (Silver POS) Plan ID: 69443TN0070004
Silver Compass 2000 (Silver POS) Plan ID: 69443TN0070003
Gold Compass HSA 1600 (Gold POS) Plan ID: 69443TN0070002
Gold Compass 1000 (Gold POS) Plan ID: 69443TN0070001
I will update the information on UnitedHealthcare on Sunday.
Update: Sunday came, and the same information was still there. It is currently there as of this edit.
ConclusionAs you can see, the market for individual health insurance on the healthcare.gov exchange for Shelby County, Tennessee is not very friendly to trans people. All plans I could verify I have shown have blanket exclusions for transgender health care, at least for surgery, with no exception or qualification. There is no statement qualifying the exclusions that says "unless it is medically necessary" in any of these plans This is surprising in light of the companies, except Humana, being lauded for selling plans that cover transgender health care. Apparently, none of those plans are being sold in Shelby County, Tennessee, though I need to still verify the story for UnitedHealthcare. People reading about insurers providing coverage should keep in mind that such coverage decisions may not apply to any of the plans available to them.
Back in 2014, Medicare overturned its exclusion of sex reassignment surgery and it was said that private insurers and Medicaid take their cue from Medicare on what to cover:
Unfortunately, when it comes to the plans available on the exchange in Shelby County, TN for 2016, it seems they've not taken any such cue.
I wanted to document these blanket exclusions to show everybody that these exclusions remain the norm, and depending on which way UnitedHealthcare turns, they seem to be ubiquitous, with no plan avaialble that provides coverage. BCBST possibly covering psychotherapy and hormones is helpful, but it does not go nearly far enough. Some employers cover it and some states require coverage, but the effects of such decisions are limited in their extent, as this map shows for states requiring coverage:
I would like to see others document the exclusions in their health plans. I think if we have thorough documentation of this, we can make a difference with regulators such as HHS, who may or may not understand the full extent of these blanket exclusions. Documenting these facts should bring the full extent of these exclusions into view, showing that contrary to popular misconception insurers in most states remain free to make blanket exclusions on transgender health care, and they have largely NOT changed their practice.
If you want, you may document exclusions on your own blog or in the comments section of this blog post. I intend to send this post to HHS once I receive confirmation on UnitedHealthcare's policies, and I intend to share it with various LGBT and trans groups. Let's all do the same!
Update: I have used this to comment on the proposed regulation.