Changes to Health Insurance in 2022
Last week, we wrote about health insurance protections for transgender and gender diverse people and tips for demystifying your coverage. This week we’d like to talk about gender affirming changes to health insurance in 2022 in Washington state and beyond.
Gender affirming changes to state insurance regulations.
In April of 2021, the Washington State legislature passed SB 5313 which expanded access to gender affirming treatment for WA Medicaid plans and other state-regulated plans. While changes to Apple Health went into effect in May, changes to state-regulated plans go into effect on January 1, 2022.
What Kind Of Health Insurance Plan Do I Have?
If you have Apple Health, these changes are in effect.
If you have an individual plan that you got on the WA Health Exchange, these changes start on January 1st, 2022.
If you need insurance, you still have time to get state-regulated health insurance! Enrollment is open until December 15th!l
Self-insured group health plans are not regulated by the state – they are regulated by the federal government. But what is a self-insured (also known as self-funded) plan? These plans are where employer assumes the risk of paying for medical care, rather than pay premiums to an insurance company.
Many employer plans are self-funded rather than insured.
Unfortunately, self-funded health plans in WA are not required to cover gender affirming care. However, benefits that are provided cannot discriminate on the basis of gender, race, age, national origin, religion, or disability. Under these plans, gender affirming care may be excluded completely by defining it as “cosmetic” (GRR) and excluding all cosmetic care.
We have a few thoughts about calling life-saving care “cosmetic.” DOUBLE PLUS GRR. We believe that gender affirming care is morally the right thing to do. It’s why we exist.
Is my plan self-funded?
The easiest way to determine if your health plan is self-funded or insured is to ask your benefits coordinator. Your plan documents may also state whether or not they are self-funded. For more information, this video and this guide from the Trans Health Project may help.
Specifics of gender affirming changes in WA insurance law:
Plans must cover “medically necessary” care. Gender affirming care cannot be categorically denied.
Highlights of changes to state-regulated plans:
- Procedures that were not covered before are now covered if they are “medically necessary.” The list of non-covered procedures is deleted. Hair removal is covered!* This can include historically difficult to access procedures like facial feminization surgery.
- Barriers to accessibility for patients and administrative barriers for providers have been removed.
- The prior authorization process has been streamlined.
“Medically necessary”
Medically necessary care as defined by the state of Washington is care that is believed to be reasonable to treat the problem. There’s an exact definition in WA state law (see below,) but in practice, medically necessary care is care that evidence, clinical knowledge, and community standards believe will help and will not worsen the patient’s condition.
For gender-affirming care, Apple Health specifically refers to the WPATH (World Professional Association for Transgender Health) Standards of Care as a community standard of care. (Side note – WPATH is expected to release SoC8 in the next year – there will likely be changes in what is considered standard practice in gender affirming care as per WPATH.)
AppleHealth provides some support and information via their TransHealth program.
“Medically necessary” is a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purposes of this section, “course of treatment” may include mere observation or, where appropriate, no medical treatment at all.
Definition of “medically necessary” as per WA state law. https://app.leg.wa.gov/WAC/default.aspx?cite=182-500-0070
What does it mean for me?
- Orchiectomy, hysterectomy, or top surgery no longer require 12 months of “lived experience.” They don’t require any “lived experience” at all!
For surgery that does require 12 months of “lived experience,”
- ”lived in the desired gender full time, in all aspects of life” is now “in a gender role that is congruent with their gender identity.”
- If 12 months is not safe for the individual, documentation of the risk to the patient is no longer required.
- Mental health evaluation assessing that the patient “will be able to comply with postoperative care plans and has the capacity to maintain lifelong changes, and that surgery is the next reasonable step” has been removed.
- 12 months of hormone treatment are no longer necessary if contraindicated or not appropriate to the client’s gender goals.
- Explicit inclusion of care for intersex folx.
- Age requirement for surgery lowered to 17 from 18.
- Mental health evaluation within previous 18 months rather than 12 months.
- Surgical letter no longer requires documentation of plans for post-operative care.
- *Electrolysis/laser is now covered for genital procedures, but the provider must be supervised by a medical professional. In Seattle, Queen Anne Medical and Polyclinic have supervised aestheticians. Documentation required for hair removal may now be provided by the person doing the procedure(s), not just the surgeon. Facial hair removal may be covered if deemed “medically necessary.”
If you’d like to read how the text of the regulation evolved, go to: https://lawfilesext.leg.wa.gov/law/wsr/2021/08/21-08-058.htm
And Beyond
Because each state regulates their Medicaid and marketplace plans, it can be hard to find information about current state and changes. Per the Movement Advancement Project, 24 states and Washington, D. C. prohibit exclusions for transition related care in state-regulated health insurance services. See other tabs for general medical care, Medicaid regulations, and state employee benefits.
One state explicitly permits insurers to refuse to cover gender-affirming care (Arkansas.)
Other States In the News Lately:
Colorado will be adding gender affirming care to their “Essential Health Benefits” in state-regulated insurance plans in 2023. Essential Health Benefits are the services and procedures that ACA rules require insurance plans to cover at least in part. ACA plans must include at least the below essential health benefits but may add more.
Essential health benefits include:
-outpatient services
-emergency services
-hospitalization
-pregnancy, maternity, and newborn care
-mental health and substance abuse services
-prescription drugs
-rehabilitative care
-lab services
-preventative care
-pediatric services
We hope many other states follow Washington and Colorado’s lead.
Do you know of insurance changes in your state that expand access to gender affirming care? Let us know!
References
Movement Advancement Project. “Equality Maps: Healthcare Laws and Policies.” https://www.lgbtmap.org/equality-maps/healthcare_laws_and_policies. Accessed 12/10/2021.
https://pubmed.ncbi.nlm.nih.gov/33422448/
