Insuring Transgender Health: Barriers and Access To Coverage For Gender Confirming Surgery

RUNNING HEAD: Insuring Transgender Health
INSURING TRANSGENDER HEALTH:

BARRIERS AND ACCESS TO COVERAGE FOR
GENDER CONFIRMING SURGERY
BY CORMAC M. POTTER
SUBMITTED MAY 8, 2015
I. Executive Summary
In the United States, most insurance plans deny coverage for gender confirming surgery.
Denial of insurance coverage renders this medically necessary treatment for gender dysphoria
inaccessible to many transgender individuals. The grounds on which insurers deny coverage of
gender confirming surgery do not reflect contemporary medical science or standards of care.
Public and private health insurance coverage should be extended for gender confirming surgery
as a medically necessary treatment of gender dysphoria.
II. Issue Statement
Problem Definition
In the United States, most public and private health insurance plans deny coverage for
gender confirming surgery (GCS; Grant et al., 2011; Institute of Medicine [IOM], 2011). These
coverage denials render GCS, a medically necessary and sometimes life-saving treatment for
gender dysphoria, inaccessible to many transgender individuals (Grant et al., 2011; IOM, 2011).
Insurers most frequently deny coverage for GCS by arguing that GCS procedures are (1)
medically unnecessary, (2) cosmetic, and/or (3) experimental (Khan, 2011). However, claims
that GCS is medically unnecessary, cosmetic, or experimental are based on outdated, incomplete,
and biased science which does not reflect contemporary medical science or standards of care
(American Medical Association [AMA], 2008; U.S. Department of Health and Human Services
[DHHS], 2014). An established body of medical research demonstrates the effectiveness and
medical necessity of GCS as a form of treatment for gender dysphoria (AMA, 2008; DHHS,
2014).
Context
Transgender. Transgender is an adjective that describes people whose gender identity
does not conform to what is socioculturally accepted as, and typically associated with, the legal
and medical sex to which they were assigned at birth.i An estimated 0.3% of adults in the United
States are transgender (Gates, 2011; Stroumsa, 2014). However, demographic studies of the
transgender population are currently limited because (1) national surveys do not include gender
identity questions, (2) there is no agreed upon differentiation among gender, gender identity, and
sex, and (3) there is no agreed upon strategy for accurately describing the transgender population
(e.g., according to self-identification, gender identity, or wish for medical treatment; Boehmer,
2002; Coulter et al., 2014; Stroumsa, 2014). Other population estimates have varied widely, from
1:500 or more to 1:50,000 or less (Stroumsa, 2014). Even using the conservative estimate of
0.3%, the number of people living in the US who identify as transgender is nearly 1 million
(Gates, 2011; Stroumsa, 2014).
Gender dysphoria. Many transgender people experience gender dysphoria (also referred
to as gender identity disorder and transsexualism), a serious medical condition recognized as
such in both the Diagnostic and Statistical Manual of Mental Disorders ii (5th Ed., Text Revision;
DSM-5; American Psychiatric Association [APA], 2013) and the International Classification of
Diseases (10th Revision; World Health Organization [WHO], 2009). The criteria for a diagnosis
of gender dysphoria are descriptive of people who experience distress caused by a sense of
dissonance between their sex as assigned at birth and their gender identity (APA, 2013; WHO,
2009). According to the American Medical Association, gender dysphoria, if left untreated, can
result in clinically significant psychological distress, dysfunction, debilitating depression and, for
some people without access to appropriate medical care and treatment, suicidality and death
(Resolution: 122 [A-08], 2008).
Gender Confirming Surgery. Gender confirming surgery (GCS; also referred to as sex
reassignment surgery, gender reassignment surgery, transsexual surgery, and transition-related
surgery) is surgery performed to change primary and/or secondary sex characteristics to affirm a
persons gender identity (World Professional Association for Transgender Health [WPATH],
2012). As appropriate to the individual, GCS may consist of one or more of a variety of surgical
procedures, including hysterectomy (removal of the uterus), mastectomy (removal of the
breasts), orchiectomy (removal of the testicles), and penectomy (removal of the penis; WPATH,
2012). Access to GCS is of utmost importance to the majority of transgender individuals, with a
reported 93% of transgender men and 84% of transgender women either having already received
or wanting to receive some form of GCS (Grant et al., 2011).
GCS is recognized as an evidence-based, medically necessary, and appropriate treatment
for gender dysphoria by the World Professional Association for Transgender Health (WPATH)
and the American Medical Association (AMA; AMA, 2014; WPATH, 2008). Some courts have
found that GCS is the only medical procedure known to be successful in treating [gender
dysphoria] (Doe v. Minnesota, 1977, 257 N.W.2d 816; Khan, 2011). The overall consensus
among those providing medical care to transgender persons is that GCS is associated with a high
i See Appendix A for additional terminology related to the transgender population.
ii See Appendix B for the DSMV Diagnostic Criteria for Gender Dysphoria.
degree of patient satisfaction, a low prevalence of regrets, significant relief of gender dysphoria,
and aggregate psychosocial outcomes that are often substantially better than before surgery (Gijs
& Brewaeys, 2007; Lantham, 2013; Lawrence, 2008; Lim et al., 2014; Monstrey et al., 2009;
Neto et al., 2012; Parola et al., 2010; Stroumsa, 2014; Udeze et al., 2008; Wierckx et al., 2011).
III. Issue Impact
Question Consequences
What are the consequences of insurance coverage denials for gender confirming surgery?
Evidence Consequences
Health. Most transgender individuals are unable to afford the cost of GCS completely out
of pocket (Grant et al., 2011). For these persons, a denial of insurance coverage for GCS erects
an insurmountable barrier between a patient and a medically necessary treatment (Grant et al.,
2011). Gender plays a significant, though often overlooked, role in our daily lives, and an
inability to to access gender confirming health care can have dire consequences for an
individual's well being (Khan, 2011). Transgender individuals who are unable to access GCS are
more likely to experience overall negative health outcomes. For example, individuals who are
unable to access desired GCS are more likely to experience social isolation, depression, anxiety,
and gender dysphoria, are more likely to engage in high risk behaviors (e.g. prostitution,
substance abuse), and are more likely to attempt suicide (Garcia, 2014; Gijs & Brewaeys, 2007;
Lantham, 2013; Parola et al., 2010; Poteat et al., 2013; Rotondi, 2012; Wierckx et al., 2011).
Discrimination. Transgender people experience discrimination as a result of living in a
gendered culture into which they do not easily fit (APA, 2009). Gender-identity discrimination
affects virtually all aspects of transgender persons lives (APA, 2009). In general, the effort
required to cope with discrimination diminishes individuals psychological resources, and
therefore, their ability to adaptively regulate emotions, which can have negative consequences
for both mental and physical health (Hatzenbuehler et al., 2013). The stress of experiencing
discrimination is associated with adverse physiological responses, including diastolic blood
pressure reactivity and increased cortisol output, which in turn may compromise health if
chronically activated (Hatzenbuehler et al., 2013).
Transgender individuals who have not undergone GCS are significantly more likely to
experience gender-identity based discrimination (Grant et al., 2011). This is particularly
problematic because transgender people are more vulnerable to poor health outcomes as a result
of discrimination. For example, transgender individuals are more likely than the general
population to abuse drugs and alcohol as mechanisms to cope with discrimination (Lombardi,
2001; Grant et al., 2011; Stroumsa, 2014). Additionally, experience of discrimination among
transgender persons has been shown to be positively and independently associated with an
increased risk for HIV, depression, and attempted suicide (Clements-Nolle et al., 2006; Grant et
al., 2011; Poteat et al., 2013).
Suicide. The transgender population has the highest suicide rate of any demographic
group, with a reported 41% of transgender individuals having attempted suicide compared to
1.6% of the general population (Grant et al., 2010; Grant et al., 2011; Khan, 2011). Transgender
individuals excessive vulnerability to suicide suggests reducing this populations risk of suicide
is of critical importance to public health. Implementing strategies known to reduce this risk
should be made an immediate public policy priority; interestingly, transgender individuals risk
of attempted suicide is significantly decreased when they are able to access GCS (Garcia, 2014;
Rotondi, 2012).
Self-treatment. Some transgender individuals who are unable to access GCS attempt selftreatment through methods that may be life threatening. For example, some transgender women
who are unable to gain insurance coverage or pay out of pocket for an orchiectomy (surgical
removal of the testicles) and/or penectomy (surgical removal of the penis) attempt self-treatment
via autocastration and/or autopenectomy (Brown, 2010; Middleton, 1997; Rotondi et al., 2013;
St. Peter et al., 2012). Autocastration and autopenectomy both carry significant health risks, such
as fatal hemorrhage, infection, and problems associated with androgen deprivation (e.g.
osteoporosis, depression; Brown, 2010; Rotondi et al., 2013; St. Peter et al., 2012; Wasserug &
Johnson, 2007). Additionally, from a financial standpoint, an elective orchiectomy and/or
penectomy costs the health care system significantly less than the cost of a hospital admission
and the associated care following autocastration and/or autopenectomy (St. Peter et al., 2012).
Health care system. The serious and expensive health problems caused by and
aggravated by inability to access GCS not only endanger transgender persons well being, but
also place a significant strain on the health care system (AMA, 2008; Kraft et al., 2009).
Furthermore, lack of insurance coverage for GCS makes health care service providers resistant to
accommodating the medical needs of transgender people (Hatzenbuehler et al., 2013; IOM,
2002; Lombardi, 2001; Stroumsa, 2014). The current failure of health care providers to
comprehensively address the medical needs of the transgender population is damaging to the
reputation and integrity of the medical profession and in contradiction to the Principles of
Medical Ethics adopted by the American Medical Association (AMA, 2000; Wichinski, 2015).
Legal. Access to GCS also has serious legal ramifications for transgender people. Most
rulemaking bodies and areas of the law place significant weight upon the question of whether or
not a transgender individual has undergone GCS in determining whether that person is male or
female, and consequently in according legal rights consistent with the individuals legally
recognized sex or gender (Bourke, 1995). The legal ramifications of ones sex or gender
designation include, but are not limited to, (1) access to accurate identity documents, (2)
marriage rights, (3) rights under probate law, (4) placement in sex-segregated facilities, (5)
liability under certain criminal statutes, (6) social security benefits, (7) military service
obligations, and (8) eligibility for protection under antidiscrimination statutes and the
Constitution (Bourke, 1995; Dasti, 2002). The legal recognition of ones sex or gender also has
significant social consequences, affecting one's ability to maintain employment, obtain medical
care, and use gender-appropriate bathrooms (Bourke, 1995; Dasti, 2002; Grant et al, 2011).
United States. Many health insurance plans in the US deny coverage for GCS through
categorical exclusions, but go on to provide coverage for the exact same surgical procedures
when they are associated with a different medical condition (e.g. a mastectomy associated with
breast cancer; AMA, 2008). According to the American Medical Association, the categorical
exclusion of these otherwise covered benefits represents discrimination based solely on a
persons gender identity (AMA, 2008). The current acceptance (and in some cases promotion) of
this discrimination is damaging to the reputation and integrity of the United States government
and the nation as a whole. In most other developed countries, including western Europe, Great
Britain, and Australia, GCS is covered entirely or in part by a national health insurance program
(Baker & Cray, 2012; Gorton, 2007; Israel & Tarver, 1997).
Inappropriate coverage denials for transgender-related care exacerbate the already
widespread health disparities experienced by the transgender population (APA, 2009; Corliss et
al., 2007; Gorton, 2007; Grant et al., 2011; IOM, 2011; Lim, 2013). The current disregard for the
unique health needs of the transgender population represents (1) a failure on the part of the
federal government to fulfill its constitutionally defined responsibility of promoting general
welfare, and (2) a failure on the part of the states to fulfill their primary responsibility of
protecting and promoting public health (Bishop & Fellow, 1928; Frieden, 2013; Karlan et al.,
2010).
IV. Change Efforts
Question Employer-Based Self-Funded Insurance
What efforts may increase transgender individuals access to employer-based self-funded
(EBSF) insurance coverage for gender confirming surgery?
Relevance. The majority of transgender individuals with health insurance have private
health insurance that is employer-based (51%; Grant et al., 2011). Sixty percent (60%) of
workers in the United States who have employer-based health insurance are enrolled in selffunded plans (Banker, 2012; Fronstin, 2012). This suggests that a substantial portion of the
transgender population is insured through employer-based self-funded (EBSF) health programs
(approximately 30%; Grant et al., 2011). EBSF insurance is also important to examine because
the percentage of workers in the US insured through EBSF health plans is increasing; the number
of individuals in the US enrolled in an EBSF health plan has increased by more than 30% over
the last ten years (Banker, 2012; Frostin, 2012).
Evidence Employer-Based Self-Funded Insurance

Overview. Self-funded insurance is a type of insurance commonly offered by large
companies to their employees (Fronstin, 2012). In EBSF insurance arrangements, the employer
provides health benefits to employees with the companys own funds (Fronstin, 2012). This is
different from fully funded insurance programs, in which the employer contracts an insurance
company to cover the employees (Fronstin, 2012). In EBSF plans, the employer assumes and
manages the direct risk for payment of employees claims for benefits (Fronstin, 2012, Goldon,
2011). This means that the employer determines the terms of eligibility and covered benefits,
which are then set forth in a documented plan (Fronstin, 2012; Goldon, 2011). The employer
may revise these terms of eligibility and covered benefits each year (Fronstin, 2012, Goldon,
2011).
Coverage determination process. Self-funded insurance programs are unique in that
they are not subject to state insurance laws or jurisdiction (e.g. mandated benefits, standards of
network adequacy; Goldon, 2011; Jensen, 2011). Self-funded health plans are regulated under
federal law only, specifically the Employee Retirement Income Security Act of 1974 (ERISA).
ERISA does not mandate self-funded plans to offer any specific coverage (Goldon, 2011; Jensen,
2011). Coverage determinations are under the discretion of the employer (Goldon, 2011; Jensen,
2011). Under ERISA, an employee cannot appeal a claim denial unless the denial is in violation
of benefits detailed in the terms of the health plan (ERISA 502(a), 29 U.S.C. 1132(a)).
Change strategy. Because coverage determination under self-funded insurance programs
are subject to such limited regulations and laws, transgender individuals access to health
coverage for GCS must be secured by convincing employers to choose to offer such coverage.
Employers coverage determinations in self-funded insurance arrangements are motivated by the
goal of offering a health plan that satisfies the needs of ones employees, while ultimately
benefiting the bottom line (Claxton et al., 2014; Taylor, 2011). Therefore, the best way to prompt
an employer to choose to offer GCS coverage is to align this choice with the employers primary
goal; one must demonstrate offering GCS coverage to be, at the very least, not harmful to the
bottom line, and ideally, beneficial to the business in the long run.
Corporate Equality Index. The Corporate Equality Index (CEI) has demonstrated the
efficacy of establishing an association between offering GCS coverage and business success. The
CEI is an annual report published by the Human Rights Campaign (HRC) that serves as the
national benchmarking tool of how equitable large private business in the United States treat
their lesbian, gay, bisexual, transgender, and queer (LGBTQ) employees (HRC, 2015-a). The
CEI is a powerful mechanism for incentivizing employers to establish equitable policies and
practices. Research shows that earning a high CEI score is good for business (Cordes, 2012;
Wang & Schwarz, 2010). High CEI scores are associated with greater success in marketing, a
competitive edge in attracting and retaining employees, improvements in stock prices, and an
overall increase in company performance (Cordes, 2012; Wang & Schwarz, 2010).
The CEI scores participating companies on a scale of 0 to 100 based on criteria grounded
in the principles of the HRCs Equality Project (HRC, 2015-a). The HRC recognizes those
business that earn a top score of 100 on its list of Best Places to Work for LGBTQ Equality iii
(HRC, 2015-a). Each year since the establishment of the CEI, the HRC has raised the bar of
scoring criteria to encourage increasingly better policies and practices of LGBTQ inclusion and
equality in the workplace (HRC, 2015-a).
Encouraging inclusion. In 2006, the HRC added specific CEI criteria related to transgenderinclusive health plans (HRC, 2012; HRC, 2015-a). In order to earn points, companies had to
offer, without exclusion, coverage for at least one of five general categories of transgenderrelated care: (1) short-term leave, (2) counseling by a mental health professional, (3) hormone
therapy, (4) medical visits to monitor hormone therapy, and (5) surgical procedures (HRC, 2012).
This criteria marked a step towards greater health care equality for transgender
individuals in the workplace. However, the leniency with which transgender-inclusion was
recognized (in that companies only had to meet one of the five general categories) limited this
change strategys impact. Of the employers that met this CEI criterion, the majority obtained
credit through short-term leave coverage, which generally does not fall under health insurance or
its exclusions (HRC, 2012).
Requiring inclusion. In 2012, the HRC increased the stringency of the transgenderinclusive health plan criteria.iv To earn and and all of the ten points allotted to this revised
criteria, employers must offer at least one company-wide health plan that covers all transgenderrelated health care, including surgical procedures (HRC, 2015-a). As a result, to earn a coveted
top score of 100 and the distinction of Best Places to Work for LGBTQ Equality, employers
must provide transgender individuals with access to health coverage for GCS (HRC, 2015-a).
Therefore, this CEI criteria effectively made offering coverage for GCS a smart business
decision.
Impact. The 2012 criteria revision led to a significant increase in the number of major U.S.
employers that offer coverage for GCS. v In 2011, 85 of the rated employers provided coverage
for GCS. This number more than doubled following the criteria revision, with a reported 206
employers meeting this criteria in 2012 (HRC, 2012). Employer-based health coverage for GCS
iii The Best Places to Work for LGBTQ Equality list is composed of highly successful and
esteemed businesses, including well-known names like Apple, General Mills, Google, Johnson &
Johnson, Microsoft, Nike, Walgreens, and Walt Disney (HRC, 2015-a).
iv See Appendix C for 2012 revised CEI criteria for transgender-inclusive health insurance.
v See Appendix D for a visual representation of the expanding number of employers that provide
health coverage for GCS.
continues to grow among CEI-rated companies, with a reported 336 and 418 employers meeting
this criteria in 2014 and 2015, respectively (HRC, 2015-a).
Accompanying the 2012 criteria revision, the HRC began asking CEI participants that provide
transgender-inclusive health benefits additional questions to gauge the financial impact of
offering such coverage (HRC, 2012). According to businesses reporting to the HRC, making
transgender-inclusive health benefits accessible comes at an overall negligible cost to their health
plans (HRC, 2015-a). Most employers reported an increase of less than one percent of total
benefits costs (HRC, 2015-a). This evidence that CEI participant employers are able to fund
trans-specific healthcare at a relatively low cost has been instrumental in convincing employers
outside the CEI sample (public, private, large, and small) to include transition-related benefits in
their health plans as well (Diskin, 2008).
Question Medicare
What efforts may increase transgender individuals access to Medicare coverage for
gender confirming surgery?
Relevance. Medicare is the second most common source of health coverage for
transgender persons, utilized by 7% of the transgender population (Grant et al., 2011). Medicare
is an important health insurance source to examine in considering past and future policy change
strategies due to the recent trend of increasingly transgender-inclusive Medicare policies (CMS,
2015-c; DHHS, 2014). Insurance providers and lawmakers often take cues from Medicare
policies on what should be considered a medically necessary covered treatment. Therefore, the
recent changes in national and local Medicare policies may present a policy window that could
facilitate policy learning and the diffusion of transgender-inclusive policies to other public and
private insurance programs (Berry & Berry, 2014; Dearing, 2009).
Evidence Medicare
Overview. Medicare is a national insurance program attached to Social Security that is
available to all citizens 65 years of age or older, as well as people with certain disabilities.
Medicare is regulated by the Center for Medicare and Medicaid Services (CMS), a federal
agency within the U.S. Department of Health and Human Services (DHHS; CMS, 2015-d). CMS
selects and relies on a network of private organizations called Medicare Administrative
Contractors (MACs) to carry out the administrative responsibilities of the Medicare program.
There are currently 12 MACs, each of which signs a contract with the federal government to
administer the Medicare program in a certain region of the United States (CMS, 2015-d).
Coverage determination process. As mandated by the Social Security Act of 1965 (Title
XVIII, Section 1862[a][1][A]), Medicare coverage is limited to services that are medically
reasonable and necessary for the diagnosis or treatment of an illness or injury. CMS and MACs
are responsible for determining the medical necessity of services through an evidence-based
review process with opportunities for public participation (CMS, 2015-d). To be deemed
medically reasonable and necessary, CMS or an MAC must find the service to be (1) safe and
effective, (2) not experimental or investigational, and (3) appropriate (CMS, 2015-d).
A coverage determination made by CMS is put forth in a National Coverage
Determinations (NCD; CMS, 2015-d). NCDs describe the circumstances for which Medicare
will cover specific services on a national basis. MACs must follow the NCDs set by CMS. vi In
cases where there is no NCD or the NCD rules are too vague regarding a specific procedure, it is
up to the MAC to make the coverage decision (CMS, 2015-d). This coverage decision is either
made on a case-by-case basis or developed into a Local Coverage Determination (LCD). LCDs
describe the circumstances in which Medicare will cover specific services in the particular region
the MAC is contracted to administer the Medicare program in (Social Security Act, Section
1869[f][2][B]).
Coverage appeals. Medicare beneficiaries in need of a service for which an NCD or LCD denies
coverage may seek to overturn the individual coverage determination or invalidate the NCD or
LCD by filing an appeal with the DHHS Departmental Appeals Board (Board) or the
Administrative Law Judge (ALJ), respectively (CMS, 2015-d). During the appeal, the
beneficiary bears the burden of proof and the burden of persuasion for the issues raised in the
NCD or LCD complaint; the burden of persuasion is judged by a preponderance of the evidence
(DHHS, 2014). The result of a successful NCD or LCD appeal may be the overturning of an
individual coverage determination or an invalidation of the NCD or LCD. NCDs and LCDs may
not be created or revised through litigation. CMS or an MAC must administer the revision or
creation of NCDs and LCDs, respectively (CMS, 2015-d).
Change strategy. Therefore, transgender individuals may garner increased access to
Medicare coverage for GCS by way of (1) the invalidation of an NCD or LCD through the
appeal of a coverage determination, and/or (2) the creation or revision of an NCD or LCD by
CMS or an MAC. The success of each of these efforts is dependent upon the provision of
sufficient evidence that GCS meets the reasonable and necessary requirements of the medical
necessity requirement of the Social Security Act.
Invalidation of a National Non-Coverage Determination. In May 2014, transgender
individuals access to Medicare coverage for GCS was increased due to the successful appeal of
an NCD. This appeal resulted in the invalidation of the blanket exclusion of Medicare coverage
for GCS (DHHS, 2014). The success of this appeal was due primarily to the strength of the
evidence presented to the Board with regard to the unreasonableness of the NCD and the medical
necessity of GCS (DHHS, 2014).
vi If an NCD is created that differs from an existing LCD, the NCD supersedes the existing
LCD.
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NCD 140.3, Transsexual Surgery. In 1989, CMS adopted a National Coverage

Determination (NCD, titled 140.3, Transsexual Surgery) categorically excluding GCS (what it
called transsexual surgery) from Medicare coverage, regardless of a persons individual
medical conditions and and physician determined needs (DHHS, 2014). The NCD was based on
an evidence-based review performed in 1982, which relied primarily on the conclusions of two
studies published in 1979 and 1981 (DHHS, 2014). The NCD states: Because of the lack of well
controlled, long-term studies of the safety and effectiveness of the surgical procedures and
attendant therapies for transsexualism, the treatment is considered experimental For these
reasons, transsexual surgery is not covered (DHHS, 2014).
Interestingly, the NCD record includes three letters from the American Civil Liberties
Union (ACLU) from 1982 disagreeing with the non-coverage determination (DHHS, 2014). The
ACLU submitted letters and affidavits from physicians and therapists supporting the medical
necessity of gender confirming surgery and taking issue with the non-coverage determination.
The record indicates that CMS chose not to defer to the ACLUs submissions on the basis that it
does not contain information about new clinical studies or other medical and scientific evidence
sufficiently substantive to justify reopening the previous assessment (DHHS, 2014).
Appellate Case. The Medicare policy change was initiated by an appeal filed by a
Medicare beneficiary (a 74 year-old transgender woman and army veteran) whose insurer denied
a physicians order for GCS (transsexual surgery; DHHS, 2014). The beneficiary filed an NCD
complaint and supporting materials illustrating how and why the NCD record was not complete
or adequate to support the validity of the NCD under the reasonableness standard (DHHS, 2014).
The record before the Board consisted of evidence and briefs submitted by the
beneficiary and six advocacy organizations serving as amici curia, including the Human Rights
Campaign (HRC), the World Professional Association for Transgender Health (WPATH),
FORGE Transgender Aging Network, the National Center for Transgender Equality (NCTE), the
Sylvia Rivera Law Project (SRLP), and the Transgender Law Center (DHHS, 2014). The
beneficiary also submitted written declarations made under penalty of perjury from a clinical
psychologist and a physician, and two notarized physician letters (DHHS, 2014). The briefs and
expert testimony were based on well-controlled, long-term studies of the safety and effectiveness
of GCS that demonstrate (1) GCS can no longer be considered an experimental treatment, and
(2) GCS has become the dominant treatment for [gender dysphoria] and the only treatment that
has been evaluated empirically (DHHS, 2014). CMS did not defend the NCD or the NCD record
in the proceeding, did not challenge any of the new evidence submitted to the Board, and did not
submit any new evidence of its own (DHHS, 2014).
The Board concluded that the new evidence indicates that the bases stated in the NCD
and the NCD record for its blanket denial of coverage for GCS, even assuming they were
reasonable when the NCD was issued, are no longer reasonable (DHHS, 2014). This
reasonableness determination was supported by the following conclusions: (a) the fact that the
new evidence is unchallenged and the NCD record undefended is significant; (b) the new
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evidence indicates acceptance of criteria for diagnosing [gender dysphoria]; (c) the new evidence
indicates that [gender confirming surgery] is safe; (d) the new evidence indicates that [gender
confirming surgery] is an effective treatment option in appropriate cases; (e) the new evidence
indicates that the NCDs rationale for considering [gender confirming surgery] experimental is
not valid (DHHS, 2014).
Impact. There is now no national exclusion for transition-related health care under
Medicare. This means transgender people receiving Medicare may no longer be automatically
denied coverage for GCS; absent the creation of a new NCD or LCDs, coverage decisions for
GCS will be made on an individual basis of medical need and applicable standards of care like
all other services under Medicare (DHHS, 2014). LCDs used to adjudicate Medicare claims for
GCS may not rely on the provisions of the invalidated NCD as a basis for denial, and CMS may
not reinstate the invalidated NCD unless it has a different basis than that evaluated by the Board
(DHHS, 2014). However, the decision does not bar CMS or MACs from denying individual
claims for payment for GCS for other reasons permitted by law (DHHS, 2014).
Creation of LCDs. In the absence of an NCD, the responsibility of determining if GCS
is reasonable and necessary, and therefore an eligible service for Medicare coverage, is passed on
to each MAC. MACs may make this coverage decision either on a case-by-case basis or develop
the coverage decision into an LCD. No LCDs have been proposed that would allow for the
automatic denial of Medicare coverage for GCS (CMS, 2015-c).
In October 2014, only three months after the invalidation of the National Non-Coverage
Determination, two MACs (Novitas Solutions Inc. and Palmetto GBA, LLC) proposed LCDs
that mandate providers to offer Medicare coverage for certain GCS procedures with prior
authorization (CMS, 2015-c). These two MACs are contracted to administer the Medicare
program in three jurisdictions (H, L, and M), which collectively encompass 15 states and the
District of Columbia (CMS, 2015-c).vii Each of the draft LCDs cite extensive evidence of the
medical necessity, efficacy, and safety of GCS, including peer-reviewed, published medical
journals, a review of available studies, evidence-based consensus statements, expert opinions of
health care professionals, and guidelines from nationally recognized health care organizations
(CMS, 2015-c). No concerns or amendments were suggested during the mandated opportunities
for public participation of the LCD review process, allowing each of the draft LCDs to be
finalized and made effective (CMS, 2015-c).
Impact. Transgender individuals with Medicare benefits in these jurisdictions who meet these
LCDs guidelines are now able to receive health coverage for certain GCS procedures.
Additionally, because no exclusionary LCDs have been proposed, transgender individuals
vii Jurisdiction H - Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma,
TexasJurisdiction L - Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania
Jurisdiction M - North Carolina, South Carolina, Virginia, West Virginia
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residing in the nine remaining jurisdictions will not be automatically denied coverage;
transgender individuals in these jurisdictions have the opportunity to gain coverage on a case-bycase basis by justifying their individual medical need.
Question Medicaid
What efforts may increase transgender individuals access to Medicaid coverage for
gender confirming surgery?
Relevance. In 2011, Medicaid was one of the least common sources of health coverage
for transgender persons (accessed by only 3% of the population; Grant et al., 2011). However,
the number of transgender persons who access Medicaid is likely to increase. The Medicaid
expansion provision of the Patient Protection and Affordable Care Act (ACA), which took effect
January 1, 2014, provides states with the opportunity to accept additional federal funding to
expand Medicaid eligibility in the state to low income Americans (CMS, 2015-a; Hill, 2012;
Skinner, 2013). In those states that have expanded Medicaid, individuals who make up to
$16,243/year for one person will now qualify for Medicaid coverage (CMS, 2015-a). Because
transgender persons are nearly four times more likely than the general population to have a
household income of less than $10,000/year, this expansion will increase the number of
transgender people eligible for Medicaid (Grant et al., 2011).
Evidence Medicaid
Overview. Medicaid is a joint state and federal insurance program attached to Social
Security that provides health coverage to millions of Americans, including eligible low-income
adults, children, pregnant women, and people with disabilities (CMS, 2015-b). Medicaid is
funded by both state and federal dollars, regulated by the Center for Medicare and Medicaid
Services (CMS), and administered by the individual states (CMS, 2015-b).
Coverage determination process. Federal Medicaid laws require states to cover certain
mandatory benefits (e.g. physician services, hospital services, screening services), under which
each participating state determines the scope and types of services it will cover; these coverage
decisions are usually codified in statute (CMS, 2015-b). The federal government has two rules
that states must follow in determining which services will be covered: (1) states may not deny
coverage of procedures solely on the basis of the diagnoses or conditions they are designed to
treat, and (2) states may only provide coverage for services that are medically necessary (Spade,
2010). Medical necessity is not defined in federal Medicaid statute; the individual states are
responsible for defining medical necessity (Spade, 2010; Skinner, 2013). Additionally, a state
may choose not to provide coverage for a service, even if a physician or the state determines the
service to be medically necessary, if the basis of this denial is considered reasonable (e.g. the
13
service is considered experimental based on sufficient evidence or lack of evidence; CMS, 2014;
Spade, 2010).
Change strategy. Transgender individuals access to Medicaid coverage for GCS may be
increased by way of (1) the invalidation of a statutory denial or exclusion through litigation, or
(2) a change in statute enacted by the state. Establishing sufficient evidence that GCS is
medically necessary is vital to, but does not guarantee, the success of these efforts under federal
Medicaid laws (Dasti, 2002; Spade, 2010).
Litigation. Most states Medicaid programs explicitly deny coverage for GCS (Casazza,
2014; Dasti, 2002; Spade, 2010; True, 2012). viii States generally deny coverage by claiming GCS
treatments are (1) medically unnecessary, (2) cosmetic, and/or (3) experimental (Dasti, 2002;
Spade, 2010; True, 2012). In the late 1970s and early 1980s there were six important appellate
court cases that addressed these denial strategies of Medicaid coverage for GCS. ix Each case
resulted in the invalidation of a common rhetorical approach to coverage exclusions of GCS; the
courts all found a categorical statutory ban on coverage for GCS to be arbitrary, unreasonable,
and in violation of federal Medicaid laws that prohibit the denial of coverage for a service based
solely on a diagnosis or condition the service is designed to treat (Dasti, 2002; Middleton, 1997;
True, 2012).
Cosmetic. Cosmetic surgery is by definition not medically necessary, and therefore not eligible
for Medicaid coverage (Stroumsa, 2014). However, states definitions of what constitutes
cosmetic surgery vary in specificity and scope. The way in which a state defines cosmetic
surgery has a significant impact on the likelihood of successfully appealing coverage denials
based on the cosmetic designation.
For example, Iowas statute defines cosmetic surgery as surgery which can be expected
primarily to improve physical appearance or which is performed primarily for psychological
purposes or which restores form but which does not correct or materially improve the bodily
functions (Iowa Administrative Code 441-78-4). The statute then goes on to state that GCS is
not considered as restoring bodily function (Iowa Administrative Code 441-78-4). This assertion
regarding the physiological utility of GCS is arguably accurate and reasonable; therefore,
successfully appealing the cosmetic designation of GCS in Iowa is unlikely.
viii Forty-three states Medicaid programs currently deny health coverage for GCS. The
remaining seven states and the District of Columbia have recently revised their Medicaid
coverage policies to allow coverage of GCS when medically necessary: California - 1978;
Connecticut 2015; Maryland 2014; Massachusetts 2014; New York 2014; Oregon 2014;
Vermont 2008; Washington D.C. 2014.
ix Doe v. Minessota (257 NW2d, 816. 1977); Rush v. Parham (440 Fed Sup, 383. 1977); Rush v.
Johnson (565 Fed Sup, 856. 1983); Pinneke v. Preisser (623 Fed 2d, 546. 1980); G.B. v. Lackner
(145, Cal Rpt, 555. 1978); J.D. v. Lacker (145, Cat Rpt, 570. 1978).
14
In comparison, California defines cosmetic surgery as surgery that is performed solely

for the purpose of altering ones structures of the body in order to improve the persons physical
appearance (California Administrative Code 22-3-1). The rhetoric of Californias cosmetic
surgery definition allowed for the success of companion cases G.B. v Lackner (145, Cal Rpt,
555. 1978) and J.D. v. Lackner (145, Cat Rpt, 570. 1978). In the two Lackner cases, the First
District Court of Appeals flatly rejected the cosmetic designation of GCS because altering ones
genitals is not a procedure sought solely for the purpose of improving ones physical appearance.
The court ruled that GCS has little in common with standard cosmetic procedures such as hair
transplants or nose alterations, and that GCS could not by the wildest stretch of imagination
reasonably and logically be characterized as cosmetic.
Experimental. Even though GCS is well established in medical literature and performed
worldwide, GCS procedures are often classified as experimental in states Medicaid regulations,
and on that basis, are ineligible for coverage. The experimental classification may be overturned
through an appeals process. In court cases challenging the denial of coverage for GCS based on
the experimental designation, the appellee must prove GCS to be a treatment generally
recognized by the medical profession as effective (Rush v. Parham [440 Fed Sup, 383. 1977]).
Rush v. Johnson (565 Fed Sup, 856. 1983) is the only appellate case that has attempted to
overturn a Medicaid coverage denial based on the experimental designation. In this case, the
court found that the state had a reasonable justification for ruling that GCS was experimental.
This conclusion was largely based on the third edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM, 3rd ed. 1980) published by the American Psychiatric Association
(APA), the most recent version of the DSM at the time. The DSM-III states: "Since surgical sex
reassignment is a recent development, the long-term course of the disorder with this treatment is
unknown."
An appeal seeking to overturn a denial based on the experimental designation of GCS
may be more successful today. In recent years, many individuals and reputable organizations in
the medical field have publicly recognized GCS as an effective treatment of gender dysphoria
(Lambda Legal, 2013). The most recent version of the DSM (5th ed., APA, 2013) does not
explicitly address the efficacy of GCS. However, the publisher of the DSM, the American
Psychiatric Association, issued a position statement that affirms: Significant and long-standing
medical and psychiatric literature exists that demonstrates clear benefits of surgical interventions
to assist gender variant individuals seeking transition (APA, 2012). This position statement also
declares that the APA supports public and private health insurance coverage for GCS and
opposes categorical exclusions of coverage for GCS (APA, 2012). The American Medical
Association (AMA), the American Psychological Association (APA), the National Association of
Social Workers (NASW), the World Professional Association for Transgender Health (WPATH),
and the American Academy of Family Physicians (AAFP) have issued similar resolutions and
policy statements (AAFP, 2012; AMA, 2008; APA, 2009; APA, 2012; Lambda Legal, 2013;
NASW, 2009; WPATH, 2008).
15
Problematic Rulemaking Response. The larger transgender population of a state may not
gain increased access to GCS coverage following a successful Medicaid appeal. Access to
coverage may even be reduced if, in response to the courts ruling, a state revises their statute to
ensure that the states Medicaid program will not be permitted to cover GCS procedures in the
future (Dasti, 2002).
For example, in Pinneke v. Preisser (623 Fed 2d, 546. 1980), Iowas Eighth Circuit of
Appeals found that (1) Iowa's denial constituted an arbitrary denial of benefits based solely on
diagnosis, type of illness or condition, and (2) Iowa's policy of denying Medicaid benefits for sex
reassignment surgery was not consistent with the objectives of the Medicaid statute. Based on
these conclusions, the court invalidated Iowas statutory exclusion of coverage for GCS, and
further, ordered the state to pay for the the appellees GCS procedure. Shortly following Pinneke,
Iowa revised the state administrative code to ensure that future appellate cases would not achieve
similar success (Dasti, 2002, Casazza, 2014). The Iowa administrative code now eliminates any
leeway in statutory interpretation by explicitly denying Medicaid coverage for GCS using a
variety of rhetorical strategies on multiple separate and distinct occasions (Casazza, 2014).x
The Eighth Circuit of Appeals has held Iowas revised legislation prohibiting coverage of GCS as
valid under federal Medicaid laws. Smith v. Rasmussen (249 F.3d 755, 760. 2001) challenged
Iowas revised statute on similar grounds as Pinnekke, arguing that the state could not place such
a limitation on medically necessary services and that the state should give deference to physician
and patient decisions (Casazza, 2014). The court held that limitations on medically necessary
services were valid as long as they were not arbitrary, capricious, an abuse of discretion, or
otherwise not in accordance with the law. Iowas revised legislation was not considered to fit
any of these criteria because the state allowed for sufficient review of the statute by the medical
community for appropriateness. This review entailed publishing notice of the intended
rulemaking action and allowing for public comment. Even though the court acknowledged it
might have been helpful or prudent for the State to have sought opinions from medical
professionals with experience in the treatment of gender identity disorder, the review was
deemed sufficient.
Legislation. Transgender individuals have gained greater access to coverage for GCS
under Medicaid in seven states and the District of Columbia, xi which have revised their states
Medicaid regulations by (1) eliminating the categorical exclusion of GCS from coverage, and (2)
adding GCS as a service that may be covered when medically necessary (CMS, 2015-b). These
coverage inclusion decisions were motivated by significant advocacy efforts and based on
extensive reviews of expert testimony, medical studies, and relevant literature regarding the
medical necessity and effectiveness of GCS (Casazza, 2014; CMS, 2015-b).
x See Appendix E for sample exclusionary language from the Iowa Administrative Code.
xi See footnote viii, at 13.
16
Oregon. For example, in August 2014, Oregon revised its statute to explicitly include Medicaid
coverage for GCS when deemed medically necessary. Prior to this, coverage for GCS was
categorically excluded from Oregons Medicaid plan. This exclusion was based on a review of
evidence related to gender dysphoria performed in 1999 (Basic Rights Oregon [BRO], 2014).
Oregons Health Evidence Review Commission (HERC) oversees the states Medicaid
program (BRO, 2014). The HERC, informed by the efforts of advocacy organizations,
determined that there was a need to evaluate the research and standards of care related to gender
dysphoria that had developed since they last looked at the topic in 1999 (BRO, 2014). The
HERC established the Value-Based Benefits Subcommittee (VBBS) to perform this evaluation
(BRO, 2014). In performing this evaluation, the VBBS was tasked with the overarching goal of
ensuring that all Oregonians who receive health coverage through Medicaid receive the most
medically appropriate care (BRO, 2014).
The VBBS heard extensive testimony from experts and reviewed relevant literature
related to the effectiveness of GCS for relieving gender dysphoria, reducing depression and
anxiety, and reducing rates of suicide and suicide attempts (BRO, 2014). Based on the evidence
reviewed, the VBBS recommended to the full HERC that coverage for GCS be added for
treatment of gender dysphoria when appropriate to the patient as determined by major
international guidelines (BRO, 2014). The HERC adhered to the VBBS recommendation and
voted to include GCS as a covered service under Oregons Medicaid program (BRO, 2014).
V. Evaluation of Evidence
Source
Corporate Equality Index. Numerous scholarly articles examine private and public
insurance policies and practices related to GCS and the way in which these policies and practices
serve as barriers to access. However, no well-controlled, long-term, or peer-reviewed studies
have been published that specifically address the transgender populations access to public or
private health coverage for GCS. Currently, CEI reports contain the only available data that
provide a long-term perspective of transgender individuals' access to private employer-based
health coverage for GCS. Therefore, the CEI is the strongest and most useful evidence available
for evaluating real changes in transgender individuals access to EBSF health coverage for GCS,
as well as factors associated with these changes.
Medicare and Medicaid Records. The evidence evaluated related to Medicare and
Medicaid is derived directly from current statute, court records, the Center for Medicare and
Medicaid Services, and Medicare Administrative Contractors. As such, it is reasonable to assume
the information discussed is accurate and complete.
Additionally, almost every Medicare and Medicaid policy change discussed was enacted
within the past ten years, and most were made within the past one year. The proximity of these
changes, and the quality of technology and record keeping at the time, increase ones confidence
17
that the record is accurate and complete. However, the fact that these Medicare and Medicaid
policy changes occurred only a short while ago limits the availability and utility of the evidence
provided. Because the only substantiated information available is that the policies have in fact
changed, it is not possible to determine the extent to which these policy changes have impacted
transgender individuals actual access to Medicare or Medicaid coverage for GCS.
Content
Confounding variables. The evidence reviewed does not extensively consider the
impact of confounding variables on the efficacy of policy change strategies. With regard to
EBSF insurance, the growth in the number businesses that offer GCS health coverage is
significant and directly corresponds to the changes in CEI criterion. However, there remains the
possibility that those employers that began offering GCS inclusive coverage did so for reasons
beyond the CEI and the established association between offering GCS coverage and business
success. Transgender individuals have recently become more visible, due in part to a growing
presence of transgender persons in the media. Transgender individuals are also becoming more
socially accepted and positively viewed. These sociocultural factors may have contributed to
employers decisions to offer transgender-inclusive health coverage, rather than being solely
motivated by the CEI and its established association.
These same sociocultural factors may have been significant contributors to the recent
revisions of some states Medicaid statutes. These statutory revisions may have also been
impacted by the culture of the states themselves. Washington D.C. and the seven states that
recently revised their statutes tend to craft more progressive policies and practices, and tend to
arrive at the forefront of policy innovation with regard to social justice and human rights issues.
Additionally, the speed with which the statutory revisions were adopted may have been impacted
by the structure of the states legislatures (e.g. part-time vs. full-time, unicameral vs. bicameral).
States that have a bicameral legislature that meets every two years for a short time (e.g. Texas)
may take significantly longer to change their statute if the state tends to be more conservative in
its policy development, or if the health needs of LGBTQ persons are not a high priority of both
the house and senate at the time the legislature convenes.
Provider networks. Provider networks are also not examined, including the availability
of competent and appropriate in-network providers or the consequences of varying degrees of
availability. This is an important limitation to note given that, if an insurance plan offers
coverage for GCS, but an individual is unable to access a competent and appropriate provider in
the plans network, one may argue that the individuals access to GCS coverage has not in fact
been increased. This limitation is also important to note given that, in the US, there is a scarcity
of competent and appropriate providers, and most professional medical education programs
provide insufficient training related to transgender care (American Association of Medical
Colleges [AAMC], 2014; Bauer et al., 2009; Cruz, 2014; Dowshen et al., 2014; Grant et al.,
2011; Johnson et al., 2008).
18
Amount of coverage. The amount of coverage provided for GCS, in terms of dollars and
percent of total service cost, is also not examined. In all three insurances discussed, a provider
offering coverage for any specific service does not mean that the provider will pay for the totality
of the cost incurred. Therefore, even if GCS coverage is provided, transgender individuals may
not be able to access the services if they are unable to afford the remainder of the cost, the
premium, or the deductible. This is particularly important to consider due to the transgender
populations high rates of under-employment (44%), unemployment (7%), and dire poverty (15%
with household income less than $10,000/year; Grant et al., 2011).
Eligibility Requirements. Finally, the impact of eligibility requirements for GCS
coverage is not examined. The public and private health insurance plans that currently offer GCS
coverage enforce a variety of eligibility requirements an individual must meet prior approval for
GCS coverage. These requirements commonly include undergoing therapy with a licensed
psychologist or psychiatrist, hormone therapy, real life experience (living socially as the gender
one identifies as), and identity document changes. Each of these requirements must be
accomplished or performed over an extended period of time, generally ranging from six months
to two years. Transgender individuals ability to complete these steps is dependent on a number
of variables, including insurance coverage, availability of providers, desire to complete, feelings
of safety, legal regulations, and the age of the recipient. Therefore, though an insurance provider
may offer GCS coverage, some transgender individuals may not be able to meet the plans
eligibility requirements, and in turn, be unable to access the GCS coverage.
VI. Moving Forward
Employer-Based Self-Funded Insurance
Recommendation. It is recommended that all employers who provide EBSF insurance
add coverage for GCS to their plans terms of eligibility and benefits. For those businesses that
cannot financially manage to offer coverage for services that are not presently justified by
employee demand, it is recommended that employers and/or human resource managers identify
whether or not there is a need to provide coverage for GCS. It is recommended that a need to
offer coverage for GCS is defined as the presence of at least one employee who meets at least
one of the following criteria: (1) diagnosed with gender dysphoria, (2) self-identify as
experiencing gender dysphoria, (3) articulated a need or desire for GCS. To account for changes
in employee populations, it is recommended that businesses re-verify the need to offer coverage
for GCS during the renegotiation of coverage eligibility and benefits that occurs in EBSF
insurance arrangements each year.
Evaluation. To evaluate the extent to which employers in the US who provide EBSF
insurance offer coverage for GCS, one may conduct a national survey of a representative sample
19
of employers in the US who provide EBSF insurance, including both large and small businesses
in a variety of professions. This survey may explicitly ask employers if they offer a health plan
that includes coverage for GCS, or may simply request that employers supply the researcher with
their plans documented terms of eligibility and benefits. Those businesses that are identified as
not offering a health plan that includes coverage for GCS should be further examined to
determine (1) the feasibility of offering coverage, (2) the presence of employee need and/or
demand for coverage, (3) the employers reasoning for not offering coverage, and (4) the
willingness of the employer to reconsider offering coverage.
Recommendation. The HRC uses Fortune Magazines 1,000 largest publicly traded
businesses and American Lawyer Magazines top 200 revenue grossing law firms as the basis for
inviting the largest and most successful U.S. employers to participate in the CEI (HRC, 2015-a).
Additionally, any private sector employer with 500 or more full-time U.S. employees can request
to participate (HRC, 2015-a). Research has demonstrated that the CEI is an effective tool for
incentivizing these large employers to choose to offer health coverage for GCS by associating
high CEI scores with success in business. Since implementing the CEI criteria related to
transgender-inclusive health benefits, the number of CEI-rated businesses that provide health
coverage for GCS has increased fivefold (HRC, 2012; HRC, 2015-a). Interestingly, the
motivation behind employer coverage decisions is generally the same regardless of business size.
Therefore, if smaller businesses are included in the CEI, this same incentive will be established
for these additional businesses. As such, it is recommended that the HRC expand the number and
scope of the CEIs sampling population to incentivize more employers to offer GCS coverage.
Evaluation. To evaluate the CEI sample expansion recommendation, one must evaluate
(1) the extent to which businesses with less than 500 employees are incorporated in the CEI
sample, and (2) the frequency with which these employers meet the transgender-inclusive health
coverage criteria, including GCS coverage. To assess the validity of ones results, one should
examine the extent to which employers decisions to offer GCS coverage were impacted by the
CEI or by confounding variables. To assess the sustainability of this recommendation, one
should evaluate the financial impact offering GCS coverage has on these smaller businesses
overall health care costs, as well as the utility of this coverage (e.g. the number of employees
who make claims for GCS).
Medicare
Recommendation. It is recommended that CMS establish an NCD that mandates
Medicare providers offer coverage for GCS when medically necessary. The adoption of an
inclusive NCD would be the most efficient policy change for increasing transgender individuals
access to Medicare coverage for GCS. Pending this national coverage determination, it is
recommended that the MACs that administer the Medicare program in the nine jurisdictions
currently without a GCS-inclusive LCD, establish LCDs that instruct Medicare providers to
20
cover GCS when medically necessary. The terms of eligibility and extent of coverage should be
modeled after the existing GCS-inclusive LCDs.
Evaluation. To evaluate the first Medicare recommendation, one must verify whether or
not CMS has established an NCD that mandates Medicare providers offer coverage for GCS
when medically necessary. This verification process simply involves a review of the NCDs
adopted by CMS, which are available to the public in the National Coverage Determinations
Index on the CMS website. If no NCD has been adopted, one may also verify if a prospective
NCD is under consideration by reviewing the Open National Coverage Analyses Index on the
CMS website. If an NCD has been adopted, to evaluate the efficacy of this recommendation in
increasing transgender individuals access to Medicare coverage for GCS, one should examine
the outcome of instances in which individuals have attempted to make a Medicare claim for
GCS, including providers resulting coverage decisions, communications between the providers
and claimants, and the providers ultimate payment actions. The evaluation process of the second
Medicare recommendation regarding the adoption of inclusive LCDs should follow the same
process as the NCD recommendation evaluation, but using the Local Coverage Determinations
Index and the Open Local Coverage Analyses Index, which are also available on the CMS
website.
Recommendation. Pending the adoption of an inclusive NCD and/or additional inclusive
LCDs, it is recommended that education efforts are made to increase coverage decision makers
competency related to the transgender population, the unique health needs of transgender
individuals, and the current standards of care related to transgender people. The goal of these
education efforts should be to ensure that GCS coverage determinations made on a case-by-case
basis are appropriate and based on medial need, rather than outdated social norms or incomplete
and inaccurate science.
Evaluation. To evaluate these education efforts, one may survey and/or interview the
educators and the coverage decision makers to examine (1) the quality, quantity, and methods of
the education efforts, and (2) the perceived and actual impact of the education efforts. To
evaluate efficacy, one may choose to survey and/or interview coverage decision makers to
determine their level of competency and knowledge related to the transgender population, the
unique health needs of transgender individuals, the standards of care related to transgender
people, and the current state of Medicare coverage policies related to transgender care. One may
also survey and/or interview transgender individuals who have sought Medicare coverage for
GCS to gather information related to their experiences negotiating with providers, including
claimants perspectives of coverage decision makers level of knowledge and competency, as well
as the outcomes of individual claims and the basis on which coverage decisions were made.
Medicaid
21
Recommendation. It is recommended that all states that do not currently offer Medicaid
coverage for GCS follow the path of Oregon and others by revising their statutes to allow
Medicaid coverage for GCS when medically necessary. Pending these statutory revisions, it is
recommended that individuals seek to overturn GCS coverage denials and exclusions through
litigation.
Evaluation. To evaluate the first Medicaid recommendation, one must examine each
individual states laws to determine if the states Medicaid program is permitted to, mandated to,
or barred from providing coverage for GCS. In those states that establish statutes that permit or
mandate Medicaid coverage of GCS, one should evaluate the efficacy of this policy change in
increasing transgender individuals access to Medicaid coverage for GCS. This efficacy may be
evaluated by examining the outcome of instances in which individuals have attempted to make a
Medicaid claim for GCS, including resulting coverage decisions, communications between
providers and claimants, and providers ultimate payment actions.
To evaluate the extent to which individuals continue to use litigation in attempts to
overturn coverage denials and exclusions, one must simply review public case records to
determine if such appeals have been filed. To evaluate the efficacy of this recommendation, one
must review the outcome of the identified appeals, including the individual coverage
determination, the impact of this determination on GCS coverage decisions for other individuals
in the state, and the impact of this coverage determination on the rulemaking body in the state.
With regard to the rulemaking body, one should examine how state legislatures have responded
to both successful and unsuccessful appeals, including public statements and policies proposed
during and following an appeal.
Recommendation. As learned from Iowa following the success of Pinneke, stakeholders
should remain vigilant of state legislation that may decrease transgender individuals access to
coverage for GCS or decrease the likelihood of success in future coverage appeals. If an
exclusionary policy is proposed, it is of critical importance that individuals and organizations,
especially those related to the medical field, publicly voice their opposition to such legislation
and educate both legislators and the public regarding contemporary medical science and
standards of care related to GCS and the transgender population.
Evaluation. In cases in which a state proposes a problematic statutory revision, one
should evaluate the extent to which individuals and organizations, especially those related to the
medical field, publicly voice their opposition to such rulemaking, as well as the impact of this
public opposition. This evaluation should include (1) the number of individuals and/or
organizations who voiced opposition, (2) the field from which these individuals and/or
organizations are from (e.g. medical doctors, lawyers, mental health professionals, political
advocates, lobbyists), (3) the method of voicing such opposition, (4) the quality of evidence
provided as the basis of opposition, (5) the impact this public opposition on the legislative
22
process, and (6) the ultimate impact of this public opposition on the states Medicaid statute
development.
VII. Conclusion
Inability to access GCS is detrimental to transgender persons health and well being.
Problematically, most transgender individuals in the US are unable to access GCS because most
public and private health insurance providers deny coverage for this medically necessary
treatment. The grounds on which insurers deny GCS coverage are based on outdated social
norms and discredited science. Public and private health insurance providers should revise their
eligibility and benefits policies to reflect contemporary medical science and standards of care. It
is recommended that categorical exclusions of coverage for gender confirming surgery are
entirely eliminated, and coverage for gender confirming surgery is made accessible.
23
Appendix A
Terminology
(APA, 2009, Task Force on Gender Identity Report; WPATH, 2012, Standards of Care 7th Ed.)
SEX. Sex refers to attributes that characterize biological maleness and femaleness. In humans,
the best known attributes that constitute biological sex include the sex-determining genes, the sex
chromosomes, the H-Y antigen, the gonads, sex hormones, the internal reproductive structures,
the external genitalia, and secondary sexual characteristics.
GENDER. Gender refers to the psychological, behavioral, or cultural characteristics associated
with maleness and femaleness.
GENDER IDENTITY. Gender identity refers to a persons intrinsic sense of being male (a boy
or a man), female (a girl or woman), or an alternative gender (e.g. genderqueer).
GENDER ROLE OR EXPRESSION. Characteristics in personality, appearance, and behavior
that in a given culture and historical period are designated as masculine or feminine (that is,
more typical of the male or female social role).
TRANSSEXUAL. Transsexual is an adjective (often applied by the medical profession) to
describe individuals who seek to change or who have changed their primary and/or secondary
sex characteristics through feminizing or masculinizing medical interventions (hormones and/or
surgery), typically accompanied by a permanent change in gender role.
TRANSGENDER. Transgender is an adjective to describe a diverse group of individuals who
cross or transcend culturally defined categories of gender. The gender identity of transgender
people differs to varying degrees from the sex they were assigned at birth.
TRANSGENDER MAN. Transgender man refers to individuals assigned female at birth who
are changing or who have changed their body and/or gender role from birth-assigned female to a
more masculine body or role.
TRANSGENDER WOMAN. Transgender woman refers to individuals assigned male at birth
who are changing or who have changed their body and/or gender role from birth-assigned male
to a more feminine body or role.
TRANSITION. Transition refers to the period of time when individuals change from the gender
role associated with their sex assigned at birth to a different gender role. The nature and duration
of transition are variable and individualized.
24
Appendix B
The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V)
Diagnostic Criteria for Gender Dysphoria
(1) A marked incongruence between ones experienced/expressed gender and assigned
gender, of at least 6 months duration, as manifested by 2 or more of the following
indicators:
a. A marked incongruence between ones experienced/expressed gender and primary
and/or secondary sex characteristics (or, in young adolescents, the anticipated
secondary sex characteristics)
b. A strong desire to be rid of ones primary and/or secondary sex characteristics
because of a marked incongruence with ones experienced/expressed gender (or,
in young adolescents, a desire to prevent the development of the anticipated
secondary sex characteristics)
c. A strong desire for the primary and/or secondary sex characteristics of the other
gender
d. A strong desire to be of the other gender (or some alternative gender different
from ones assigned gender)
e. A strong desire to be treated as the other gender (or some alternative gender
different from ones assigned gender)
f. A strong conviction that one has the typical feelings and reactions of the other
gender (or some alternative gender different from ones assigned gender)
(2) The condition is associated with clinically significant distress or impairment in social,
occupational, or other important areas of functioning, or with a significantly increased
risk of suffering, such as distress or disability
Subtypes
With a disorder of sex development
Without a disorder of sex development
25
Appendix C
2012 Present, CEI Criteria for Transgender-Inclusive Health Coverage
10 pts. - Equal health coverage for transgender individuals without exclusion for medically
necessary care:
Insurance contract explicitly affirms coverage and contains no blanket exclusions for
coverage
Insurance contract and/or policy documentation is based on the World Professional
Association for Transgender Health (WPATH) Standards of Care
Plan documentation must be readily available to employees and must clearly
communicate inclusive insurance options to employees and their eligible dependents
Benefits available to their employees must extend to transgender individuals. The

following benefits should extend to transgender individuals, including for services related
to gender transition (e.g., medically necessary services related to sex affirmation/
reassignment):
o Short-term medical leave
o Mental health benefits
o Pharmaceutical coverage (e.g., for hormone replacement therapies)
o Coverage for medical visits or laboratory services
o Coverage for reconstructive surgical procedures related to sex reassignment
o Coverage of routine, chronic or urgent non-transition services
o Plan language ensuring adequacy of network or access to specialists should
extend to transition-related care (including provisions for travel or other expense
reimbursements)
Dollar maximums on this area of coverage must meet or exceed $75,000.
To secure full credit for benefits criteria, each benefit must be available to all benefits-eligible
U.S. employees. In areas where more than one health insurance plan is available, at least one
inclusive plan must be available.
Appendix D
Transgender-Inclusive Health Coverage Expansion
The number of major employers in the CEI sampling population that offered transgenderinclusive health coverage, including GCS coverage, in the corresponding year.
26
Appendix E
Iowa Administrative Code
Iowa Administrative Code r 441-78.1(4) (2013):
For the purposes of this program, cosmetic, reconstructive, or plastic surgery is
surgery which can be expected primarily to improve physical appearance or which
is performed primarily for psychological purposes or which restores form but
which does not correct or materially improve the bodily functions . . . . Surgeries
for the purposes of sex reassignment are not considered as restoring bodily
function and are excluded from coverage.
Iowa Administrative Code r 441-78.1(4)(b) (2013):
Cosmetic, reconstructive, or plastic surgery performed in connection with
certain conditions is specifically excluded. These conditions are: (2) Procedures
related to transsexualism [or] gender identity disorders
Iowa Administrative Code r 441-78.1(4)(b)(d)(15) (2013):
[f]ollowing is a partial list of cosmetic, reconstructive, or plastic surgery
procedures which are not covered under the program (15) Sex reassignment.
27
28
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