Transition Coverage and Clarity in Self-Insured Corporate Health Insurance Benefit Plans

Abstract

While many health insurance plans now cover at least some gender-affirming care for transgender persons, no study to date has examined contract language about gender-affirming care in self-insured corporate plans. We sought to evaluate private company offerings from the perspective of an employee, analyzing clarity as well as what gender-affirming care is covered or excluded. Methods: We coded 435 health insurance contracts from 40 U.S. self-insured corporations from 2019 for inclusion of 52 coverage aspects from the World Professional Association for Transgender Health (WPATH) recommendations. We categorize contracts by clarity of the document and its inclusions and exclusions, and compare each company's contract ratings to their 2019 Human Rights Campaign (HRC) Workplace Equality Index rating. Results: Findings reveal higher levels of total exclusions in contracts (9% here vs. 3% found in prior studies of more highly regulated plans), as well as extensive variation in clarity, coverage specifications, and types of exclusions. Facial confirmation surgery procedures are commonly excluded even in plans that affirm the WPATH guidelines. Twenty-five percent of the companies in the study offered at least one contract with a categorical exclusion. HRC ratings did not match up to our ratings of gender-affirming coverage. Conclusion: Legal complexity has resulted in a patchwork of continued health insurance exclusions of genderaffirming care even as coverage has expanded. Lack of transparency and clarity also contributes to challenges in understanding one's own coverage as well as mapping the national picture of transgender inclusion in health care plans.

Gender affirming hormone therapy dosing behaviors among transgender and nonbinary adults

“…A prior study found that uninsured trans people were less likely to be on any hormone treatment than insured trans people (Stroumsa et al, 2020). Even for people with insurance coverage, exclusions of gender-affirming care, including hormone therapy, persist among people with public insurance (particularly state Medicaid programs) and people with private insurance plans (Dowshen et al, 2019;Kirkland et al, 2021;Zaliznyak et al, 2021). Similarly, while the literature on distance traveled to access gender-affirming services like hormones is scant, existing research illustrates a willingness to travel further distances to access knowledgeable providers that are capable of providing genderaffirming healthcare (Cicero et al, 2019;Kattari et al, 2020).…”

Health and health care access in the US transgender population health (TransPop) survey

“…2 These medical interventions may not be covered by insurance, compounding cost-related delay of care. [25][26][27] TransPop, USTS and BRFSS-based studies consistently indicate a younger age demographic for transgender people. Age significantly affects insurance coverage and health access in the United States, with young adults less likely to have adequate insurance.…”

“…In addition, access to gender affirming care plays a significant role in health for many transgender people 2 . These medical interventions may not be covered by insurance, compounding cost‐related delay of care 25–27 …”

Increasing inclusion & competency in STEM: Understanding LGBTQ+ history, barriers, and heteronormativity

“…Furthermore, insurance often does not cover LGBTQ+ needs to the same extent as it covers for cis-heterosexual individuals [68], particularly as some affirming medical care is considered cosmetic by insurance companies [65,76,77]. There is also difficulty in accessing insurance when there is gender-specific coverage (e.g.…”

“…coverage of cancer screenings), or gender-affirming care is considered cosmetic [e.g., mastectomies, breast augmentation, hair grafts, voice therapy, etc. ; , 76,77]. Even LGBTQ+ organizations, like the Human Rights Campaign, may not adequately assess comprehensive trans healthcare policies [76], requiring an added burden navigating insurance and healthcare for trans and nonbinary individuals.…”