INTRODUCTION: Historically, access to gender transition-related healthcare has been limited. In May 2014, the US Department of Health and Human Services (HHS) prohibited insurance discrimination of transgender individuals. Despite this legislative shift and the international standards of care recommended by the World Professional Association for Transgender Health (WPATH), there are continued insurance disparities; health insurance plans often lack explicit guidelines on gender transition-related care and coverage of surgical procedures is varied. We evaluated the evolution of insurance coverage of gender-affirming care following the 2014 legislative change.
METHODS: We selected the largest and most popular insurance companies based on market share. We then conducted a web-based search and telephone interviews to identify the corresponding policies related to gender-affirming healthcare. We compared policy changes made before and following the 2014 HHS decision. Policy revisions were categorized into 3 groups: (1) coverage of services, (2) medical necessity criteria, and (3) terminology.
RESULTS: Of the 92 insurers surveyed, 7% (n = 6) did not have a policy. We documented a total of 315 policy revisions. Most policies were established (54%, n = 48) and most policy revisions occurred (75%, n = 236) after the HHS decision. After the legislation, a significantly higher proportion of policy revisions were related to coverage of services (36% versus 11%; P < 0.0001), removal of existing criteria significantly decreased (23% versus 49%; P = 0.0044), and addition of criteria unrelated to WPATH standards sharply increased (32% versus 2%; P = 0.0002). This resulted in reduced coverage of facial feminization, hair transplantation, laryngochondroplasty, and voice modification surgery. However, nipple reconstruction experienced increased coverage. The percentage of revisions to add preauthorization criteria to meet WPATH standards (49% versus 45%; P = 0.6714) or to change terminology (37% versus 27%; P = 0.1055) were similar before and after the legislation.
CONCLUSION: Following the transformative legislation in 2014, an increasing number of insurance companies established gender transition-related policies. Additionally, more revisions were dedicated to coverage status, which may reflect the continually changing attitudes to gender-affirming procedures, such as facial feminization. As more patients seek gender-affirming care, insurers appear to deviate from international guidelines and create additional benchmarks that may act as barriers to care.