Medicare Lifts Blanket Exclusion On Covering Transgender Surgical Procedures

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"Medicare Lifts Blanket Exclusion On Covering Transgender Surgical Procedures"

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The U.S. Department of Health and Human Services Departmental Appeals Board (DAB) announced Friday that it has overturned the Medicare policy of categorically excluding coverage for gender transition–related surgical procedures that are medically necessary for many transgender people.

The DAB, an independent administrative entity within HHS, ruled that the ban is unreasonable and contrary to contemporary science and medical standards of care. This ruling is consistent with the consensus of the medical and scientific community that transition-related care is medically necessary and effective treatment for many people with gender dysphoria. The lifting of the coverage exclusion means that transgender Medicare beneficiaries will now be able to seek individualized review of the medical necessity of the specific procedure they need, just like anyone seeking coverage for any other medical treatment.

The ruling is the latest in a nationwide wave of developments among employers, regulators, and insurers affirming the legitimacy of transgender people’s medical needs and removing discriminatory barriers to care.

In 2013, the Corporate Equality Index compiled by the Human Rights Campaign found that more than a quarter of Fortune 500 companies now offer coverage to their employees that is fully inclusive of transgender health needs.

And over the last 18 months, regulators in six states plus the District of Columbia have issued bulletins clarifying that state nondiscrimination law prohibits insurance policy clauses that exclude coverage for transgender people.

The most recent bulletin, released by the D.C. Department of Insurance, Securities, and Banking in February 2014, explicitly follows the same reasoning as the DAB in recognizing that decisions about the medical necessity of care related to gender transition, including surgeries, should be based on consideration of the individual’s needs and the health care provider’s recommendations.

The Colorado Association of Health Plans, which represents 11 major insurers that together insure more than 3 million Coloradans, responded to a similar bulletin promulgated by the state’s Department of Regulatory Agencies by issuing a statement saying existing transgender exclusions will not be enforced and will be removed from future plan filings.

The DAB ruling striking down the Medicare exclusion follows 30 years of changes in the scientific understanding of transgender people’s health needs. Since the Medicare coverage ban was instituted in 1981, an entire generation of research and practice has demonstrated that access to transition-related care, including hormone therapy, mental health services, and surgeries, significantly improves the health of transgender people and that exclusions blocking coverage put patients’ lives at risk and undermine the ability of medical professionals to appropriately care for their patients.

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