A. Almazan1, O. Ganor1, E. Boskey2 1Harvard Medical School,Boston, MA, USA 2Boston Children’s Hospital,Department Of Plastic And Oral Surgery,Boston, MA, USA
Introduction: A recent movement to pass state-based non-discrimination laws has led to mandatory coverage for gender-affirming surgical care in many private insurance plans. However, it is unclear whether these laws have improved access to treatment for transgender patients. While more plans may cover gender affirmation surgery, restrictive medical necessity criteria used by insurers to decide reimbursement can still delay treatment or preclude access to surgery for many patients. In this study, we examine how coverage and medical necessity criteria for gender affirmation surgeries vary between states that do and do not have laws protecting coverage of gender-affirming medical care in private insurance.
Methods: Medical coverage guidelines for surgical treatment of gender dysphoria were taken from the websites of the largest insurer in each state by market share.
Expansiveness of coverage for each insurer was assessed by examining whether each plan offered any of the following procedures: FTM phalloplasty, MTF vaginoplasty, FTM mastectomy, MTF augmentation mammoplasty, electrolysis, and laryngoplasty.
Restrictiveness of medical necessity criteria was assessed by examining whether each plan mandated any of the following prerequisites for gender affirmation chest surgeries: proof of social transition, documentation of hormone therapy for FTM mastectomy and MTF augmentation mammoplasty, documentation of legal name change, and proof of employment/schooling/community involvement.
Each state was labeled according to whether it had a law protecting insurance coverage of gender affirmation surgery. The number of covered procedures and number of chest surgery prerequisites were compared between states that did and did not have transition-related protections.
Results: The mean number of procedures covered in states with legal protections is 4.81, compared to 3.92 in states without protections (t=-2.32, p=0.013). The mean number of pre-requisites for chest reconstruction surgeries in states with legal protections is 0.88, compared to 0.92 in states without protections (t=0.10, p=0.46).
Conclusion: Insurers in states with non-discrimination laws protecting transition-related insurance coverage tend to cover more gender-affirming surgical procedures. However, the number of requirements that must be fulfilled to deem a chest reconstruction medically necessary is effectively identical between insurers in states that do and do not have non-discrimination laws. Transition-related insurance protections are associated with enhanced coverage of gender affirmation surgery. However, they are not associated with improvements in the restrictiveness of medical necessity criteria, which may still act as a barrier to care even when coverage is nominally increased in accordance with these laws.