FAQ on the Insurance Division Announcement

| January 3, 2013 | Comments (0)

Frequently Asked Questions

On DCBS/Insurance Division Bulletin regarding transgender health needs

OVERVIEW
The Oregon Department of Business and Consumer Services (DCBS) released a bulletin in December 2012 announcing that in order to comply with current statutes prohibiting gender discrimination, health insurance plans sold in Oregon can no longer deny care to transgender policy holders which is provided to non-transgender (or “cisgender”) policy holders. Removing these outdated exclusions brings Oregon up-to-date with the latest information from medical experts and will provide countless Oregonians with access to medically necessary health care. To read the bulletin, please click here:  http://www.oregon.gov/DCBS/insurance/legal/bulletins/Documents/bulletin2012-01.pdf

WHAT IS DCBS AND WHAT AUTHORITY DOES IT HAVE?
DCBS oversees health insurance in the state of Oregon. Insurance companies must comply with the Insurance Code and DCBS rules that implement the Insurance Code in order to sell insurance in the state. The bulletin is intended to serve as notice to insurers and others of the department’s expectations about how insurers and producers must act in transacting insurance in order to comply with Oregon’s non-discrimination law, Senate Bill 2.

WHAT KINDS OF EXCLUSIONS DOES THE DECISION IMPACT?
The bulletin specifically states that:

  • Health insurers must provide coverage and cannot deny coverage of treatments for transgender policy holders if the same treatments are covered for other policy holders. If an insurer covers breast reduction surgery to lessen back pain, the insurer could not deny breast reduction surgery for gender transition if the provider deemed the treatment medically necessary. If hormone therapy is covered for other policyholders, it cannot be denied for gender transition if determined to be medically necessary. On the other hand, an insurer could exclude all coverage of breast implants or penile implants. In short, Oregon law requires equality in treatment.
  • Health insurers may not have riders that categorically exclude all transgender patients.
  • The statewide mandate for coverage of mental health services must apply to transgender patients of all ages.
  • The designation of male or female may not be relevant to treatment (ie, a person cannot be denied an ovarian cancer screening on the basis that they identify as male).

WHAT DO I DO IF I THINK AN INSURER HAS UNFAIRLY DENIED MY CLAIM?

  1. You must file an appeal through the insurance provider. Your appeal will likely be denied by your insurance company and they may include more than one step of appealing. You must complete all levels of internal appeal with the insurer.
  2. At the same time as you are going through the appeals process, file a complaint with DCBS. You may receive help with your complaint from an insurance consumer advocate by calling 1-888-877-4894 or by going to this website: http://www.oregon.gov/DCBS/insurance/gethelp/Pages/fileacomplaint.aspx
  3. DCBS can determine whether or not your complaint is eligible for the external review process. Once you have exhausted the internal appeals process through your insurer, you may have the option appeal to an impartial medical panel for an external review. The state contracts with five entities that provide medical health professionals to populate the panels. This panel is composed of medical professionals who are unaffiliated with insurance companies. The medical provider(s) on the panel must have some knowledge of the area of the case.
  4. Through this external review process, the decision of the insurance company to deny coverage will either be upheld or overturned. DCBS Consumer Advocates are able to assist consumers through this process.

BUT WHAT IF THE INSURER COVERS THE SAME PROCEDURES FOR OTHERS? ISN’T THIS FLAT OUT DISCRIMINATION? 

If the insurer is denying a claim for a treatment for a transgender-related condition but allows the same treatment to others for non-transgender-related condition simply by saying “this is not covered” then DCBS may use existing non-discrimination statutes to require the insurer to provide coverage for the treatment of a transgender-related condition.  The availability of this option can only be made on a case-by-case basis, as many things influence the outcome, such as terms of the policy itself, reasons the carrier denied the claim or refused to approve the treatment, coverage provided to others seeking the same treatment for other reasons, etc.  When an insurer denies a claim based on “medical necessity,” the insurance company is essentially disagreeing with a doctor about the medical necessity of a procedure. DCBS cannot enforce statute about what defines “medical necessity” because laws do not exist which define this specifically and most insurers define medical necessity in their contract. However, because of the changes in the rule and expectations set forth in the bulletin, most insurers will likely have to make a determination that a treatment is not medically necessary in order to deny coverage.  In this case you now have access to an external review process administrated by DCBS. A Consumer Advocate from the Insurance Division can assist you through this process free of charge, but DCBS cannot make the determination of medical necessity.  DCBS strongly urges an insured person to participate in this process if a claim is denied on the basis of medical necessity.

WHY IS THIS DECISION NEEDED?
Insurance companies routinely refuse to provide insurance to transgender people based on their transgender status or specifically exclude transgender-related services. Nearly all insurance plans categorically excluded coverage for transgender-related medical treatment, even when that treatment (such as mental health care or hormone replacement therapy) is covered for non-transgender people. This kind of categorical exclusion is no longer permitted.

IS THIS NECESSARY MEDICAL CARE?
Our nation’s most reputable medical bodies have identified transgender health care as being medically necessary. In 2008, the American Medical Association passed a resolution supporting public and private health insurance coverage for treatment of gender identity disorder and opposing the “exclusions of coverage for treatment of gender identity disorder when prescribed by a physician.” That same year, the American Psychological Association passed a resolution stating that the organization “opposes all public and private discrimination on the basis of actual or perceived gender identity and expression and urges the repeal of discriminatory laws and policies;. And in 2012 the American Psychiatric Association affirmed that the organization “Urges the repeal of laws and policies that discriminate against transgender and gender variant individuals.” and “Opposes all public and private discrimination against transgender and gender variant individuals in such areas as health care, employment, housing, public accommodation, education, and licensing.”

WILL THIS RAISE INSURANCE RATES?
Past experience offers helpful information here. In 2010, Multnomah County removed exclusions from their employee health plan and in 2011 the City of Portland followed suit. Both municipalities have seen no significant cost impact to their health plan. For example, the City of Portland estimated the premium impact to be .08%. The City and County of San Francisco removed exclusions from their employee benefits plan in 2001 and have not seen any discernible increase in health care costs.

HOW WILL THIS AFFECT MEDICARE AND MEDICAID?
Because Medicare and Medicaid (Oregon Health Plan) are federally funded, it is unclear if this bulletin will apply. What is clear is that the ruling will apply to all private insurance companies that operate in Oregon. Basic Rights Oregon and transgender community leaders will continue working together to increase access to medically necessary care for all Oregonians.

HOW DOES THIS DECISION IMPACT HEALTH REFORM?
Under the Affordable Care Act, each state decides what is included in their health plans. This decision means that insurance companies participating in Oregon’s health exchange will need to comply with the mental health parity rule and the expectations set forth in the bulletin.

WHO ELSE IS PROVIDING THIS COVERAGE AND WHY?
Currently, 25% of Fortune 100 Companies and many Oregon businesses, both large and small, offer inclusive health care, including healthcare for transgender employees. These businesses believe that providing all employees with the medically-necessary care they need to be healthy and productive is not just good for employees and their families, they know it is good for business.

Oregon businesses that offer transgender-related coverage to their employees include:Oregon Health and Sciences University (OHSU), New Seasons, the National College of Natural Medicine, Portland State University, Progressive Insurance,  Starbucks, Alcatel-Lucent, American Express, Ameriprise Financial, AT&T, Bank of America, Chrysler Motors, IBM, Kimpton Hotel & Restaurant Group, KPMG, Kraft Foods, McGraw- Hill, Microsoft, and State Farm.

To download this document in PDF form, click here: BRO DCBS FAQ Updated FINAL

For more information, contact Basic Rights Oregon at 503-222-6151 or email david@basicrights.org.

Category: Resources: Transgender Justice

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