Shopping for health insurance is complicated. Shopping for health insurance as a transgender person is way more complicated.
Despite advances in equal rights for transgender people and the recent visibility of trans celebrities, such as Ian Harvie and Caitlyn Jenner, healthcare equality for transgender people is still way behind.
One of my friends, Jamie, is in the process of medically transitioning. Though he still qualifies for coverage as a dependent on his parents’ plan, their policy is not transgender-inclusive. Recently, as he’s been searching for a job post-graduation, Jamie has seen getting a health insurance policy through work as his best option (60% of people still receive healthcare benefits through their job).
Despite living in New York, one of the few states with anti-discrimination laws for transgender people, Jamie has still found getting health insurance and healthcare to be a treacherous experience.
What is a transgender-inclusive health insurance policy?
To be transgender-inclusive, a health insurance policy needs to have no exclusionary statements referring to transgender-related healthcare. In addition, it should have affirmative statements, specifically stating that the policy covers healthcare services like gender reassignment surgery, hormone therapy, mental health counseling, and other medical visits. You can see examples of clinical policy bulletins referring to transgender-related healthcare at the Human Rights Campaign.
There is one major misconception about transgender-related healthcare, which usually presents itself in arguments made by both politicians and health insurance companies alike: that gender reassignment surgery is not "medically necessary." This is untrue: medically transitioning through surgery and hormone replacement therapy is a key part of treating gender dysphoria. In most states, surgery is a requirement before official documentation, such as birth certificates and state IDs, can be updated to reflect a trans person’s gender transition.
States with anti-discrimination laws
There are multiple states with bans on insurance exclusions for transgender healthcare: California, Oregon, Washington, Colorado, New York, Massachusetts, Connecticut, and Vermont. Some of those states also offer transgender-inclusive health benefits for state employees; in addition, Maryland and Minnesota offer these health benefits to federal employees but don’t have anti-discrimination laws. (In the case that you’re reading this and progress has been made at a state level, you can visit the Human Rights Campaign for an updated map.)
Asking about trans-inclusive insurance during the job search
It can be really difficult to find out if a job has trans-inclusive health insurance. It makes the job search exponentially more difficult than it already is, as Jamie found out post-graduation. "[I do feel] a real time crunch to getting a job with benefits, inspired by the consistent physical pain and emotional difficulty of dysphoria."
When he asks interviewers at organizations and businesses if their health insurance package covers trans-related healthcare, it "makes interviewers really uncomfortable. On top of that, they almost never know what the insurance covers." And while job discrimination against transgender people is illegal in most of New York, including the county Jamie lives in, outing oneself in a job interview is problematic; besides forcing someone to violate their own privacy rights in order to collect necessary information, discrimination exists even with laws to prevent it.
If you’re looking for a job right now, the Human Rights Campaign has compiled a list of corporations that have transgender-inclusive health insurance benefits. If you’re looking at a job at one of those organizations, you’ll have at least one option for transgender-inclusive health benefits.
There are other companies and businesses that offer transgender-inclusive benefits that are not on that list. It can be almost impossible to find out if a small business’ health insurance offering is trans-inclusive if you are not an employee of that company. You may be able to find a public way to contact a company's HR department – assuming they have one – but there’s no guarantee they will answer you.
Asking about trans-inclusive insurance at your current workplace
If you are currently working at a company and want to figure out if they offer trans-inclusive health insurance, start by requesting the summary information about their health insurance plans. By law, summaries need to be readily available to any employee. Unfortunately, summaries can be a bad place to look for information: they’re frequently out of date and ambiguous when it comes to trans-related information.
Your next (and best) step is to ask someone at your company. However, this brings its own set of concerns related to privacy. Here’s the most important thing you need to remember: if someone is not bound by HIPAA, your conversation should not be considered private.
What is HIPAA? HIPAA is short for the Health Insurance Portability and Accountability Act, which lays down privacy rules pertaining to health information.
To best protect your privacy, you should get verbal (and, if you can, e-mail or written) confirmation that the person you’re talking to has to comply with HIPAA before you ask any questions about trans-related benefits. The Human Rights Campaign has more information and a great list of questions that you can use when requesting HIPAA information.
There’s a good chance that people within your organization do not know if the company health insurance plan will cover trans-related healthcare. In most cases, you should attempt to contact your health insurance company directly.
Lobbying for change within your company
One of the misconceptions that the Human Rights Campaign is trying to fight is that employers can’t change their health benefits package or that they have little control over their health benefits package.
Not only do companies have the power to look for a better health insurance company to provide their benefits, they can also negotiate with their existing health insurance company to remove transgender-related exclusions from their coverage and add affirmative inclusions.
You can lobby for change within your company using some of the same avenues we described above. Your HR department, if it exists, is the best place to start. In this situation, it may be difficult to retain your privacy – in other words, becoming an activist for change at your company may inherently out you. If you face discrimination after being outed, you may not have much legal recourse, based on where you live and what laws apply.
If you don’t identify as transgender, you can still lobby for change within your company. Whether you’re in human resources, the CEO of your company, or a regular employee, you can help push your company to offer inclusive health insurance and adopt anti-discrimination policies. Check out the Human Rights Campaign for more employer resources.
One misconception among employers is that transgender-inclusive health insurance is more expensive. This is not the case: because transgender people represent such a small part of the population, providing healthcare benefits for them is incredibly cheap. In fact, there’s a high chance that there would be no additional cost.
Looking on the marketplace
While the Human Rights Campaign has put together a list of carriers with publicly available guidelines for transgender-related healthcare, you should not consider these carriers your only options. Instead, if you’re shopping on the marketplace, you should look at these guidelines as an example of the kind of language you should be looking for in plans you are considering. You should find the language in either the Evidence of Coverage or Certificates of Coverage (both serve the same purpose).
Some state marketplaces do not feature full explanations of what is covered, instead using benefit summaries. Benefit summaries rarely feature transgender-related language, even if the plan itself does affirmatively cover transgender-related healthcare. If your state marketplace uses benefit summaries, contact the administrators of the marketplace or a local application assistant and ask to see the Evidence of Coverage or Certificates of Coverage.
In states with bans on transgender-related exclusions in health insurance plans (listed above), all of the plans on the marketplace should cover transgender-related healthcare services. Look for language in the plans similar to the publicly available guidelines in order to guarantee that the plans are following state law.
Until last year, gender reassignment surgery was not covered by Medicare, but a lawsuit spurred the Department of Health and Human Services to reassess the ban. The surgery is now available to anyone receiving Medicare benefits. Generally, most people over the age of 65 qualify for Medicare (read the full eligibility requirements here).
Though the amount of people the policy change covers is likely to be low (you can read about some of them here), it’s likely to have a ripple effect through the healthcare industry; health insurance companies typically look to Medicare when deciding what their policies should cover.
Unfortunately, even if you find a health insurance plan that covers transgender-related care, there’s no guarantee you’ll receive the care you need. This applies to standard care as well.
The last time Jamie had to go to the hospital for emergency care, he had to make sure that his friends used his "legal name and gender when interacting with the hospital staff for fear they wouldn’t treat me, or wouldn’t treat me appropriately." While Jamie told hospital staff that he was taking testosterone, "no one asked me how much T I was on, how long I’d been on it – any of the things that were probably important to know."
Another issue that crops up for transgender people is getting healthcare for body parts that don’t align with their affirmed gender. For example, people assigned female at birth will usually still require PAP smears, while people assigned male at birth usually still need to be screened for prostate cancer. Some hospitals and healthcare centers will refuse to provide these basic health services to trans people. Insurance may also no longer cover it, as those services are typically tied to gender.
The National Center for Transgender Equality has put together an FAQ about healthcare rights for transgender people, which is a great place to start if you feel you’ve been discriminated against (or for preparing yourself against possible discrimination.)