The State of Insurance Coverage for Gender-Affirming Care
Gender-affirming care means many things to many people. Generally, it includes various supportive services from non-medical up to surgical care for transgender and nonbinary (TNB) people. In the insurance world, we tend to think about gender-affirming care in terms of having an equitable benefit offering to address the affirmation needs of any member.
However you define it, the research shows that gender-affirming care is critical to creating better outcomes for TNB youth. In a group of 104 transgender and non-binary youths — ages 13 to 20 — receiving gender-affirming care, “including puberty blockers and gender-affirming hormones, was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up.” While many state and national governments have been taking steps to roll back access to gender-affirming care, especially for young people, insurance companies have quietly made strides toward making it more accessible.
A short history of gender-affirming care
Not long ago, gender-affirming care was hard to come by and expensive. Most patients had to pay out-of-pocket for much-needed care, which was inconvenient, expensive, and, most importantly, inequitable.
In the pre-COVID era, I was at a client’s office when the receptionist stopped me on my way out and asked if she could speak to me briefly. We entered a conference room where she told me about her struggles getting the gender-affirming surgery she needed. For the first time, the issue of gender-affirming care was on my radar in a meaningful way, and I left the office determined to make a change.
For about 18 months, I took every chance I had when communicating with Aetna — this particular client’s carrier — to discuss the topic and attempt to influence the company’s coverage. Then, in January of 2021, Aetna announced it was expanding coverage for transgender people: “Aetna, a CVS Health company, with the Transgender Legal Defense & Education Fund (TLDEF) and national civil rights law firm Cohen Milstein Sellers & Toll, today announced that Aetna has expanded coverage of gender-affirming surgery to include breast augmentation for transfeminine members of most of its commercial plans.”
Four trans women — including the client I talked to in the conference room that day — were instrumental in this change. Nancy Menusan, Cora Brna, Allison Escolastico, and Elissa Gaytan helped bring “access-to-care issues to Aetna’s attention after being denied coverage for breast augmentation as part of their gender-affirming treatment.” Once Aetna’s domino fell, the other companies followed suit. However, while access is expanded, TNB people must still navigate many hurdles before getting the care they need.
Bureaucratic barriers to getting gender-affirming care
As is so often the case when it comes to insurance, nothing is as easy as it seems. For instance, when Aetna announced the expansion of its coverage to include breast augmentation as medically necessary, it detailed the requirements TNB individuals would have to provide: “a letter of referral from a qualified mental health professional; persistent, well-documented gender dysphoria; and the completion of one year of feminizing hormone therapy prior to breast augmentation surgery.”
Similar criteria exist for other gender-affirming surgeries, such as breast removal, gonadectomy or hysterectomy, and genital reconstruction. But gender-affirming care includes so much more than just surgery. From hormone therapy to psychotherapy, TNB people require a wide variety of care, just like the population at large — but it’s sometimes complicated by the laws where a patient lives. Furthermore, access to mental healthcare and hormone therapy is required to meet the criteria for later surgical intervention.
In many U.S. states, bills have been introduced to prevent children from getting gender-affirming care — most notably, preventing them from getting access to puberty-blocking drugs. Whether or not an insurance policy can cover gender-affirming care in these states depends on where the policy is domiciled. A company headquartered in South Dakota is subject to South Dakota’s anti-trans laws. But suppose a company is headquartered in Connecticut, and its policy is written in Connecticut. In that case, the policy is only subject to Connecticut’s laws, even if the company has employees in South Dakota. Members in South Dakota may need to travel to access care, but it’s still covered.
3 questions to ask insurance providers about gender-affirming care
Wherever you’re located, HR and benefits professionals must ask their insurance carriers the right questions before purchasing a new policy.
What are the details of gender-affirming care coverage? Does it only cover hormone therapy, or does it also cover medically-necessary surgery? And what does the company consider medically necessary? Mental health care is also essential to think about, as coverage isn’t always a given but is often required to meet the criteria for gender-affirming surgery.
What are the criteria to qualify for care? The barriers to receiving gender-affirming surgery can be many. Ensure you understand what they are before purchasing a plan if this is likely a concern for your team members.
What is the coverage for ongoing treatment? Again, gender-affirming care is wide-ranging and means something different for everyone. It’s important to ask whether ongoing care — such as hormone therapy — will be covered long-term.
Insurance companies often err on the side of being cryptic and intentionally vague regarding policy. So it’s not only imperative that you ask the direct question, it’s often necessary to get the experts involved. At Allegiant Global Partners, we take our clients’ coverage personally and pride ourselves on going to bat for them. Whether it’s explaining coverage language or following up with carriers to change their policies, we are here to help.