California commissioner: Trans youths cannot be denied insurance for surgery
Legal opinion says insurers must consider individual care assessments when determining medical necessity.
California’s Department of Insurance has issued an opinion clarifying that, under existing law, health insurance companies operating in the state may not deny coverage for male chest reconstruction surgery for transgender patients undergoing care for gender dysphoria based solely upon their age.
State law already provides protections intended to reduce barriers to gender-affirming care. But trans Californians, parents, and advocates have complained that some insurance companies still use criteria or processes that result in wrongfully deny coverage for gender-affirming care, forcing patients to go through a time-consuming process to appeal such decisions.
Last week, State Insurance Commissioner Ricardo Lara directed the department to issue a general counsel opinion letter clarifying that transgender youth seeking chest reconstruction surgery — with the approval and consent of their parents — may not be categorically denied coverage for the procedure.
“For far too long, individuals diagnosed with gender dysphoria have had to battle a host of challenges to get access to gender-affirming care in order to be their true selves,” Lara said in a statement. “Social stigma, misconceptions about gender dysphoria and its treatment, and outdated medical criteria create barriers to necessary medical care that can lead to tragic results for individuals with gender dysphoria, especially for our transgender youth.”
Typically, insurers only provide coverage for a particular procedure when it is considered medically necessary to treat a given condition. But the Insurance Department found that insurers must consider each patient’s individual circumstances when determining medical necessity. That finding comports with guidelines from the World Professional Association for Transgender Health, an international professional association that recommends standards of care for transgender people, which advises that chest reconstruction surgery may be approved for individuals under 18 “depending on an adolescent’s specific clinical situation and goals for gender identity expression.”
The department also opined that imposing age limits on chest reconstruction surgery when it is used to treat gender dysphoria, but not other medical conditions, such as breast cancer or trauma, violates a host of state and federal laws prohibiting discrimination based on age, sex, gender identity, gender expression, sexual orientation, and health conditions.
The clarification from the Department of Insurance came about in response to an inquiry from the San Diego-based TransFamily Support Services regarding several instances in which trans male patients under age 18 were denied coverage for chest reconstruction surgery.
“TransFamily Support Services is proud to partner with the California Department of Insurance to remove the age barrier for gender-affirming care,” Kathie Moehlig, the group’s executive director, said in a statement. “This barrier was discriminatory and detrimental to the lives of trans youth. To have to navigate the overwhelming barriers to health care should not be a part of their experience. Transgender youth already face so many challenges from unsupportive families, bullying at school, social stigmas, and even violence.”
In a press release, Lara’s office noted that in order to be proactive, insurance companies should evaluate their coverage criteria for gender dysphoria treatment and eliminate any practices that would conflict with the department’s interpretation of law.
“Today, the State of California has put insurance companies on notice that they cannot deny access to medically-necessary care based on outdated rules that are not supported by evidence or scientific consensus,” Dr. Ward Carpenter, the co-director of Health Services at the Los Angeles LGBT Center, said in a statement. “In so doing, the state not only expands access to health care but also takes an important step in saving the lives of transgender and nonbinary adolescents struggling with gender dysphoria, depression and suicidal thoughts. Decisions about an adolescent’s health must be left to the patient, their families and their care providers, not to insurance companies.”
Assemblymember Evan Low (D-Cupertino), an openly gay lawmaker and chair of the California Legislative LGBTQ Caucus, praised the insurance department’s legal opinion as something that would “not only improve people’s health but also their quality of life.”
“Every patient, including those experiencing gender dysphoria, deserves to have their specific clinical situation taken into consideration,” Low said in a statement. “Discrimination does not have a place in California and should not have a place anywhere in health care.”
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