Coalition Led by Callen-Lorde Prompts State to Issue New Medicaid Guidance on Gender Affirming Insurance Coverage

Last week, the New York State Department of Health quietly released new guidance for Medicaid Managed Care Plans informing coverage of treatment of gender dysphoria. The guidance comes as a welcome development when – despite existing regulations that went in to effect in 2015 – many transgender and gender non-binary (TGNB) patients are being denied coverage for gender affirming care and surgeries.

“This is an exciting development for our communities,” said Dr. Asa Radix, Senior Director for Research and Education.  “For far too long transgender and gender non-binary people have been denied access to gender affirming care due to arbitrary insurance rules that go against best clinical practice. The new Medicaid guidance sends a powerful message that healthcare plans must follow well-accepted standards of care and allow trans and gender non-binary people to access medically necessary care that aligns with their individual goals.”

The guidance standardizes the policies, procedures and coverage criteria for the authorization and utilization management of hormone therapy and surgery for mainstream Medicaid Managed Care plans, HIV Special Needs Plans and Health and Recovery Plans and goes and into effect September 1 of this year.

Callen-Lorde – noticing a trend of increased insurance denials for its TGNB patients since 2016 – has led a statewide coalition – the NYS Trans Health Working Group – pushing the state Department of Health (public plans), Department of Financial Services (commercial plans) and decision makers to hold insurance plans accountable.  As a community health clinic with a large TGNB patient population, Callen-Lorde is actively working with TGNB patients who have been denied coverage for gender affirming care by their insurance plans. Approximately 16% of Callen-Lorde’s TGNB patients seeking support for gender affirming care or surgeries are denied coverage, resulting in hundreds of hours of staff time and delayed or no care for patients.

The new guidance mandates the policies and procedures and coverage criteria must be submitted to, and approved by, the New York State Department of Health before making service authorization request determinations. The guidance is responsive to many of the issues raised by Callen-Lorde and the Trans Health Working Group and, on its surface, seeks to reduce arbitrary administrative barriers that plans seemingly had put in place to stall or deny coverage. The four-paged guidance includes the following important clarifications, among others:

  • Plans must accept the treating doctor’s determination that the gender affirming care requested is medically necessary.
  • Plans may impose prior authorization requirements but must accept the treating provider’s assessment. Further, when a provider makes this determination, plans cannot require that patient enrollees submit photographs in order to document the need for treatment. These requirements have led often to the plan replacing a doctor’s treatment recommendation with that of the plan’s own arbitrary determination of what was best for the patient.
  • Before making an adverse determination, the plan must make at least one attempt to consult with the treating provider, and at least one of the plan’s clinical staff involved in the adverse determination must have expertise in the treatment of gender dysphoria.
  • Plans cannot require that patient enrollees have at least 12 months of continuous mental health counseling prior to surgery, but instead must be dependent on the patient’s clinical profile, which means that this duration may be shorter as appropriate.
  • Similarly, plans cannot require a year of hormone therapy prior to all procedures, and can only require hormone therapy if it is consistent with the patient enrollee’s gender goals, clinically appropriate, and recommended by the treating provider.
  • Plans criteria has to include a definition of gender dysphoria consistent with best medical standard, must recognize that gender dysphoria affects people of all genders and is not limited to people with binary identities.
  • Two letters from qualified medical providers must attest to the patient enrollee’s need for the requested care. The guidelines now clarify that these letters must be viewed in tandem.
  • Finally, plans cannot require that the two qualified professionals submitting letters must work for different organizations, which is very important for patients at an integrated facility like Callen-Lorde where they can see both mental health and primary care providers.

The guidance was published shortly after Manhattan Pride, when Governor Cuomo announced his own additional protections for transgender New Yorkers, in anticipation of a potential roll back of the Affordable Care Act’s key non-discrimination provision, Section 1557. Cuomo (1) directed the State Department of Health to issue a regulation requiring all New York State hospitals to update their statements of patient rights to prohibit discrimination against transgender patients (2) he directed the state Department of Financial Services (DFS) to issue new regulations expanding anti-discriminations protections for transgender individuals seeking access to health insurance in both large and small group policies and (3) he directed DFS to issue a circular letter reminding industry participants that discrimination on the basis of gender identity is already prohibited.

“The new Medicaid guidance coupled with Governor Cuomo’s proactive steps to protect the health and well-being of TGNB New Yorkers signal renewed momentum,” said Kimberleigh J. Smith, MPA Senior Director for Community Health Planning and Policy at Callen-Lorde. “Our elected officials and decision makers are hearing us and taking action. We’re optimistic that this response ultimately will help improve the health of our TGNB communities.”