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Terminar las exclusiones trans: el camino hacia la atención médica inclusiva

Many of the existing inclusions for LGB—and particularly—T people have been hard won over the last 20 years. On Monday, June 16,  four major organizations met to take stock of the history and trajectory for LGBT inclusions in healthcare.

On the open community call, “With Medicare Done: How We Can Win the Rest," NCTE’s Mara Keisling moderated the discussion among Jennifer Levi, Director of the Transgender Rights Project at Defensores y defensores gays y lesbianas (GLAD), Andrew Cray, Policy Analyst for LGBT Progress with Centro para el Progreso Americano (CAP), and Beck Bailey, Deputy Director of the Workplace Project with Campaña de Derechos Humanos (CDH).

The discussion opened with a summary of the recent widespread progress, including the Obama administration’s announcement yesterday of his intention to issue an executive order to protect LGBT people employed by federal contractors and the Medicare decision issued 12 days ago.


The History of the Medicare Decision– Jennifer Levi

Jennifer Levi, Director of the Transgender Rights Project at Gay & Lesbian Advocates & Defenders discussed the recent win with Medicare as the culmination of a 30+ year history.

Medicare is the federal program that provides insurance coverage for seniors and some people with disabilities. Levi talked about the fact that Centers for Medicare & Medicaid Services (CMS) sometimes issues what it terms national coverage determinations (NCD’s) to make a global statement about services that either may or may not categorically be covered by Medicare.  In order to maintain an NCD, the law requires it to be reasonable.  In other words, an NCD must be medically and scientifically supported.

On May 30, 2014, the Department of appeals board issued a decision that the Medicare exclusion of trans surgeries is not valid. Levi explained that this has four major implications:

  • There is no categorical basis now to deny SRS
  • There is no categorical statement about the need for/efficacy of SRS in any particular individual’s case; rather, the need for SRS must be determined on the basis of an individual assessment
  • The decision made by the appeals board did not address other non-surgical requests; Hormone coverage was not previously excluded and should be covered in appropriate cases
  • CMS has 30 days from the date of finalizing the board’s decision to implement it

The decision means that in the future, transgender patients covered by Medicare should receive an individual coverage determination for requested surgical care of gender dysphoria, and their preauthorization cannot be summarily denied (note: this does not mean it is summarily allowed).  Levi also addressed some of the short-term challenges the community may face in finding Medicare participating providers.

The attorneys who handled the case, GLAD, ACLU, and NCLR, are eager to hear from individuals about how it is going and want to know about any challenges faced during the implementation.


Raising the bar: Modernizing standards- Andrew Cray

In the last few years, there has been widespread recognition of trans-inclusive care as the medical standard and the removal of barriers to care as a modern necessity.

Many agencies and organizations have made strides to align themselves with contemporary medical practices, including (Office of Personnel Management’s Federal Employee Records and Department of Health and Human Services). Even this past Friday, the Office of Personnel Management (OPM) announced that Federal Employee Health Benefits (FEHB) are in negotiations and have been asked to decide if they will explicitly cover (or not cover) gender transition related healthcare benefits for 2015 on. It is unclear whether every carrier will provide coverage, but it means each carrier will decide by 2015.

Andrew Cray, Policy Analyst for LGBT Progress with CAP, outlined several the strides toward modernization seen recently by state-level insurance commissioners, Medicaid, and the ACA.

Often, state-level insurance commissioners are responsible for setting private insurance regulations. Six states (California, Colorado, Connecticut, Oregon, Vermont, and DC) have ruled that exclusions for transition related care are discriminatory and have taken action to remove the exclusions.

Medicaid, the state regulated program that offers insurance to low-to-no-income individuals and families, has also seen progress in several states. The state Medicaid directors for California, Vermont, and DC, have all made the decision to include transition related care and many more directors are working towards it.

With the Affordable Care Act in place, the insurance exchange marketplaces have already become an essential space for health benefits and will cover millions in the next few years. A major benefit is that plans sold through health insurance marketplaces are not allowed to discriminate on the basis of gender identity.  In addition, trans individuals can appeal unfair exclusions and that the law is consistently coming down on the side of trans inclusion.


Keeping the Private Sector Competitive: LGBT Inclusions - Beck Bailey

During the call, Beck Bailey, Deputy Director of the Workplace Equality Program with HRC, outlined the strides made in the business arena because of the Indice de Igualdad Corporativa (CEI). The CEI is a tool introduced by HRC in 2002 to benchmark LGBT inclusion in corporate environments and educate the corporate community about inclusive practices.

In 2004, the CEI criteria required corporate workplaces to provide at least one medically necessary component of trans-inclusive coverage. Additionally, HRC’s Índice de Igualdad en la Atención Médica (HEI) has been designed to gauge where healthcare organizations stand in comparison to healthcare best practices as defined by the CMS and Joint Commission.

By 2009, a core group of 50 corporate workplaces provided baseline trans inclusive coverage in line with the clinical guidelines provided by WPATH (including hormones, mental health coverage, SRS, and supporting coverage). By 2014, the CEI had 340 employers with at least one baseline plan for trans inclusive care.

In the future, the CEI will be used to elevate the profiles of companies and businesses that exceed the baseline norms, highlighting the best practices.

For individuals working in corporations that haven’t completed the CEI or do not currently have transgender inclusive healthcare coverage, urge your Human Resources department to begin the process. The HRC provides trans resources to support you, and the Transgender Law Center also has a guide to advocate for coverage with your employer. Additionally, Bailey offered a few talking points for would-be activists:

  • Does the organization already have a nondiscrimination policy that includes gender identity and expression? Adding coverage is consistent with this coverage.
  • Benefits account for 20% of an individual’s total compensation. Coverage is a matter of equal pay for equal work.
  • Most trans services are covered for people with other conditions. The trans exclusions are arbitrary. The American Medical Association recognizes the necessity of equitable coverage.
  • Cost is not a real barrier, because costs are low. Employers around the country that have implemented insurance inclusions have seen little to no change in costs.
  • Return on investment is high because it saves money when the right treatment is provided for the right medical condition.
  • Providing coverage is necessary to get a 100% designation on the CEI and be listed as “One of the best places to work for LGBT people”


Paving the path ahead - Mara Keisling

With all the momentum so far, we can expect more to come on the path to healthcare inclusion. The last month has seen a series of wins in governments, agencies, and organizations. Even still, many more agencies will resolve their exclusions, including the VA the DOD. Ultimately, many advocates feel that there are only a few years left until we achieve the elimination of all these discriminatory insurance exclusions.

While many national advocacy and legal organizations are leading the charge forward, individuals can help to build momentum by sharing their stories. NCTE, GLAD, CAP, ACLU, NCLR, TLC, TLDEF, and Lambda Legal all want to know if organizations are facing implementation challenges or individuals are facing issues accessing benefits. It also helps to share continued developments at state and local levels of what is going right; these can become the basis for good guidance and best practices and implementing the progress.

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