July 27, 2015 — Transgender individuals face barriers accessing health care services despite federal rules that bar insurers from using gender or health history to deny coverage, Kaiser Health News/CNN reports.
Under the Affordable Care Act (PL 111-148), insurers cannot deny coverage because a person is in the process of transitioning. Further, recent guidance from the Obama administration states that insurers cannot refuse to cover sex-specific preventive services to transgender individuals.
Gendered Insurance Forms
When individuals purchase individual or small group market plans, they must note their gender as either male or female. That selection corresponds with a code, and an individual only can receive services that match the code, according to Robin Maril, senior legislative counsel at the Human Rights Campaign.
However, if an individual is transitioning from one gender to another, he or she could still have organs that correspond with his or her gender at birth. For example, most transgender men have a cervix, meaning they still need to have a Pap test, according to Harvey Makadon, director of professional education and training at Fenway Community Health, a Boston LGBT health center. Further, it can take several years to complete the transition process entirely.
The insurance setup means that some transgender individuals opt to remain uninsured or mark their gender at birth on their insurance identification cards, KHN/CNN reports. Maril said, "The idea that you have insurance and you're still being denied basic care is outrageous."
In addition, issues with insurance can exacerbate what can already be a stressful experience for transgender individuals seeking health care. Eli Strong, who transitioned from female to male, noted, he "put off having annual (gynecological) exams ... because it was also so incredibly uncomfortable to be a bearded man in a gynecologist's office."
America's Health Insurance Plans, the insurance industry's trade organization, said insurers are complying with the law. AHIP spokesperson Clare Krusing said, "Health plans want to make sure patients have access to the care they need" and "[p]lans do cover medically necessary care and preventive services for transgender individuals."
For example, according to KHN/CNN, Kaiser Permanente said it has a process in place to resolve claims that have been denied based on gender. Aetna said it had a similar way to resolve such claims, and is working to separate services from members' gender.
In addition, the insurance industry has said that providers should be responsible for clarifying a patient's health service needs. A provider can state a patient is transgender in notes included in a claim submission, according to the industry.
Advocates Say Issue Is Not Resolved
However, Dru Levasseur, of Lamdba Legal's Transgender Rights Project, said shifting responsibility to the provider does not always work. Levasseur noted most billing systems are automated and services such as prostrate exams and mammograms are flagged to match a certain gender. He explained that a claim is automatically denied if the gender does not correspond with a service and must be manually resolved.
Sarah MacCarthy, a health researcher at RAND Corporation, said while there were no reliable data on coding issues related to denials, "there's a lot of anecdotal evidence that it's challenging to access services, and even if they are accessed, they continue to be of low quality."
Meanwhile, AAPC, a trade group for medical coders, and transgender advocates said private insurers could put in place specific transgender coding options as Medicare does. According to KHN/CNN, Medicare uses codes that permit providers to note that an individual is transgender, which means that claims for services such as Pap tests can be processed.
Advocates said they are aiming to incorporate new categories -- such as "transgender woman" or "transgender man" -- into the insurance application forms as well as research initiatives to better understand coverage denials among transgender individuals and how such denials relate to health outcomes (Gillespie, Kaiser Health News/CNN, 7/27).
Report: Trans Women Face Health Care Disparities, High HIV Rates
In related news, discrimination against transgender individuals results in health care access disparities, which can been seen in high HIV prevalence among transgender women around the world, according to a World Health Organization report, NPR's "All Things Considered" reports.
In a meta-analysis, researchers looked at HIV prevalence among transgender women in 15 countries. Data from countries in Africa and Eastern Europe was not available at the time the report was written.
JoAnne Keatley, study author and director of the University of California-San Francisco's Center for Excellence for Transgender Health, said the meta-analysis found that transgender women are 49 times more likely than the general population to have HIV. Further, transgender women sex workers are nine times more likely to have HIV than other women sex workers.
In an interview with NPR, Keatley said the higher rates of HIV among transgender individuals likely has to do with stigma. She said, "I think a lot of it is stigma-driven. Trans people struggle in order to obtain identity documents that allow them to participate in the workforce. Many trans people are not able to obtain health coverage." Keatley added, "What is driving the epidemic is really the refusal -- I would say -- of governments to pass legislation that allows them to function in society, and allows them to participate in the workplace."
However, she also pointed to some recent progress in lowering HIV prevalence among transgender individuals, noting that the WHO policy brief aims to educate governments and health ministries about HIV and transgender individuals ("All Things Considered," NPR, 7/26).