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Gender Transition-Related Care Exclusions Prohibited For Medicaid Plans

Issue Backgroundgender-transition-non-discrimination-sign

On July 18, 2016, the Pennsylvania Department of Human Services released its guidance on implementing a non-discrimination provision for Medicaid and CHIP that protects people from discrimination based on gender identity. Specifically, the commonwealth lifted its ban on insurance coverage for medically necessary gender transition-related health care through Medicaid and CHIP plans, which significantly expands access to care for many low-income Pennsylvanians.

With this change, it is now illegal for Medicaid contracted insurance providers to “have or implement a categorical exclusion or limitation for all health services related to gender transition,” meaning that they cannot include trans-specific coverage exclusions in health insurance policies.

Unfortunately, while this language prohibits providers from explicitly excluding gender transition-related services, it does not mean that plans are required to include language that affirms their availability. Each claim will be handled on a case-by-case basis by Medicaid providers.

Understanding How It Works

The insurance carrier may not refuse to cover a medically necessary transition treatment that is available for use with other medical conditions – for example hormone therapy – simply because it is being prescribed to treat gender dysphoria or because it is prescribed to a transgender individual. The carrier must have a legitimate and nondiscriminatory reason for limiting access to a medical treatment that would be available to someone with a different diagnosis.

Similarly, it is unlawful to refuse coverage of gender-specific treatment because an individual is a different gender than that listed on their insurance documents or assigned at birth. As such, health services that are ordinarily available only to an individual of a particular gender – like mammograms or prostate exams – must be provided when appropriate or necessary. This change eliminates denials based on “mismatched” gender information which has obstructed access to preventative services in the past.

Getting Started

To access care, individuals will need to submit documentation. For example, Medicaid will require medical provider documentation that is consistent with World Professional Association for Transgender Health (WPATH) criteria when providing coverage for gender transition-related services. Alder Health Services offers qualified professionals who can assist with the navigation of this system.

To request assistance, please contact Alder Health Services at: 717-233-7190 ext. 248

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