Posted on by Helen Boyd

DC Mayor Announces Trans Health Policy

via the DC city blog:

Mayor Gray Announces Steps to Protect GLBT Community from Discrimination in Health Care

(WASHINGTON, DC) – Today, the District of Columbia advanced the rights of the city’s transgender community by prohibiting discrimination in health insurance based on gender identity and expression. Mayor Vincent C. Gray announced the Department of Insurance, Securities, and Banking (DISB) is issuing a bulletin to District health insurance companies addressing the application of anti-discrimination provisions in the insurance code, including recognizing gender dysphoria, or gender identity disorder, as a recognized medical condition.

“Last March, the District began the process of removing exclusions in health insurance on the basis of gender identity or expression. Through the hard work of my Office of GLBT Affairs and a multi-agency working group lead by my Chief of Staff, Chris Murphy, we have today taken the necessary steps to completely eliminate these exclusions,” said Mayor Gray.  “Today, the District takes a major step towards leveling the playing field for individuals diagnosed with gender dysphoria. These residents should not have to pay exorbitant out-of-pocket expenses for medically necessary treatment when those without gender dysphoria do not. Today’s actions bring us closer to being One City that values and protects the health of all of our residents.” 

This action follows DISB’s March 15, 2013 bulletin notifying health insurers to remove language that discriminated on the basis of gender identity and expression from their policies and permit those with gender dysphoria to obtain medically necessary benefits. Today’s action goes one step further in protecting this community’s health insurance rights by affirming that gender dysphoria is a recognized medical condition and thereby treatment, including gender reassignment surgeries, is a covered benefit. To view the full bulletin, click here: http://disb.dc.gov/publication/disb-bulletin-13-ib-01-3013-revised-prohibition-discrimination-health-insurance-based

“This action places the District at the forefront of advancing the rights of transgender individuals,” Mayor Gray said. “It also fully implements the District’s Human Rights Act by incorporating gender identity and expression as protected classes in the District’s health insurance laws.”

Moreover, individuals with gender dysphoria are entitled to receive any medically necessary benefits and services under individual and group health insurance policies covering medical and hospital expenses. In determining the medical necessity of services and benefits provided to individuals diagnosed with gender dysphoria, insurance providers must refer to the World Professional Association for Transgender Health Standards of Care, known as WPATH, the recognized standard of medical care for transgender individuals requiring treatment for gender dysphoria. These benefits are not newly mandated, but rather clarify District law to assure that individuals diagnosed with gender dysphoria are afforded the same benefits under health insurance policies as individuals seeking medically necessary treatment for non-gender identity or expression-related conditions.

In keeping with today’s insurance bulletin, the Department of Health Care Finance (DHCF) and the Department of Human Resources (DCHR) clarified their policies as well. DHCF ‘s position is that the District’s Human Rights Act (DCHRA) prohibition on discrimination in government services on the basis of gender identity and expression is consistent with Medicaid coverage standards. The benefits afforded to individuals seeking treatment for gender dysphoria, including gender reassignment surgeries, should not be construed as newly-mandated Medicaid benefits. As with all covered services provided through Medicaid, the District of Columbia will continue to cover medically necessary transgender health services to the extent permissible through Federal and local law. DHCF’s intent is to ensure that individuals diagnosed with gender dysphoria are afforded the same right to obtain the full measure of benefits as individuals seeking medically necessary treatment for non-gender identity or expression related conditions; or as they themselves would experience for non-gender identity related health care concerns. To view the DHCF memo click here: http://dhcf.dc.gov/publication/MedicaidPolicy-GenderIdentity

Similarly, DCHR’s position is that an individual diagnosed with gender dysphoria also falls within the protected class of “gender identity or expression” in the DCHRA.  DCHR will ensure that benefit and coverage exclusions and limitations that explicitly or otherwise target enrollees on the basis of their gender identity or expression are removed from health insurance plans offered to DC Government employees. Moreover, DCHR will ensure that insurers administering health insurance plans to DC Government employees cease denials, exclusions, or other limitations on coverage for medically necessary services, in accordance with the WPATH Standards of Care, including gender reassignment surgeries, if such items or services would be covered for other plan enrollees without regard for their gender identity or expression. Any health plan documents, riders or health plan provisions currently in effect that are inconsistent with the guidance of today’s insurance bulletin are hereby void and unenforceable. Likewise, any riders that charge an additional premium for benefits that are under the bulletin to be covered by an individual or group insurance policy should be eliminated no later than the next renewal period. Click here to view the DCHR memo: http://dchr.dc.gov/release/dc-government-prohibits-discrimination-health-insurance-policies-based-gender-identity-or

 

Non-Discrimination in the District’s State Medicaid Program Based on Gender Identity or Expression

Consistent with BULLETIN 13-IB-01-30/13 REVISED issued by the Department of Insurance, Securities and Banking (DISB), the Department of Health Care Finance (DHCF) issues a clarifying statement of policy pertaining to the District of Columbia’s Medicaid program, gender identity or expression, and access to care.

Medicaid covers approximately one-third of District residents, making it a major contributor to the high insurance coverage rates enjoyed by the District of Columbia.  Additionally, the comprehensive benefits provided by Medicaid are essential to the health and well-being of some of the District’s most vulnerable residents. DHCF endorses the District’s prohibition of discrimination in health insurance based on gender identity or expression, and further states that, while there is no evidence that there are policy barriers to access to care for District Medicaid beneficiaries seeking medically necessary sexual reassignment treatment, surgery, or other therapeutic services, the perception of providers and beneficiaries may be that Medicaid does not cover such services.  Through this statement, DHCF confirms and clarifies that treatments and services related to the treatment of gender dysphoria are covered by Medicaid when they are determined to be medically necessary.

The benefits afforded to individuals seeking treatment for gender dysphoria, including gender reassignment surgeries, should not be construed as newly-mandated Medicaid benefits.  As with all covered services provided through Medicaid, the District of Columbia will continue to cover medically necessary transgender health services to the extent permissible through Federal and local law.  Rather, DHCF is committed to ensuring that individuals diagnosed with gender dysphoria are afforded the same right to obtain benefits under health insurance policies as individuals seeing medically necessary treatment for non-gender identity or expression related conditions; or as they themselves would experience for any other health care concerns.

Medically Necessary Services and Medicaid

If a District resident is eligible for Medicaid coverage in the District, and enrolls in the Medicaid program as a participant, that individual is eligible for all medically necessary covered services, as defined by the Medicaid State Plan. Key points pertaining to medical necessity in Medicaid include:

  • There are express terms and limits on State discretion with regards to medical necessity in Medicaid programs. The first such limit is a requirement that a State’s medical necessity standard be reasonable (42 U.S.C. § 1396a(a)(17)(A). The second limit requires that a State’s medical necessity standard be consistent with the purpose of a particular Medicaid benefit. The third limit prohibits States from arbitrarily denying coverage on the basis of a condition in the case of a required service.
  • The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) provisions of federal law create a unique medical necessity standard for children under age 21(42 U.S.C. §§ 1396d(a)(4)(B) and 1396d(r)). The standard requires States to provide any “necessary health care, diagnostic services, treatment, and other measures” that are needed to “correct or ameliorate defects and physical and mental illnesses and conditions.”
  • In determining the medical necessity of services and benefits provided to individuals enrolled in Medicaid, providers should refer to recognized professional standards of medical care.  For transgender individuals requiring treatment for gender dysphoria, such standards are detailed in the most recent edition of the World Professional Association for Transgender Health Standards of Care[1] Inasmuch as the WPATH Standards indicate that the appropriate course of treatment for individuals diagnosed with gender dysphoria may vary between patients, determinations of medical necessity for coverage purposes must also be guided by providers in communication with individual patients.
  • For surgical procedures that are determined to be medically necessary, but may be cosmetic  in nature :
    • Section 9 (Clinic Services) Part A in Supplement 1 to Attachment 3.1-B in the DC Medicaid State Plan states “Surgical procedures for medically necessary cosmetic purposes (except for emergency repair of accidental injury) will be provided only by prior authorization issued by the State Agency.[2]

[1] The World Professional Association for Transgender Health (WPATH). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People.
[2] In its review of claims data from the Medicaid Management Information Systems (MMIS), DHCF has found no indication or pattern of denying claims on the basis of gender identity. Many procedures in the MMIS system that a provider may bill for throughout the course of offering treatment to a patient in transition do not require prior authorization.