Pennsylvania Dept of Human Services lifts exclusions on transition related care in Medicaid plans


*This post was authored by Mazzoni Legal Intern Barri Friedland


We reported last week on a major advance for trans and gender variant Pennsylvanians who rely on state-funded health insurance. The Pennsylvania Department of Human Services has lifted bans on insurance coverage for medically necessary gender transition related healthcare in PA Medicaid and CHIP plans. 


This is big news, as it will significantly expand access to care for low-income Pennsylvanians. We congratulate all of the many advocates who've worked for this long-awaited change.


The background


The Affordable Care Act, passed in 2010, is the first federal civil rights law to prohibit discrimination on the basis of sex in health care. Section 1557 is the civil rights provision of the ACA. On May 18 of this year, the U.S. Department of Health and Human Services’ Office of Civil Rights issued a final rule on clarifying Section 1557, which prohibits discrimination based on gender identity. Pennsylvania guidance on implementing the non-discrimination provision for Medicaid and for CHIP was released on July 18, 2016.


What it means


It is now explicitly unlawful for Medicaid contracted insurance providers to “have or implement a categorical coverage exclusion or limitation for all health services related to gender transition.” This means that insurance plans contracted by Medicaid may not include trans-specific coverage exclusions.


While trans-specific exclusions are no longer legal, this does not mean that all transition-related care will be automatically and easily available. There is no requirement that plans include language affirming the availability of coverage for services related to gender transition. Just as each individual has unique transition needs, these claims will be handled on a case by case basis by Medicaid providers. 


How it works


If a medically necessary transition treatment is available for use with other medical conditions, as is the case with hormone therapy, the insurance carrier may not refuse to cover that same treatment simply because it is being prescribed to a transgender individual or being used to treat Gender Dysphoria. There must be a legitimate nondiscriminatory reason for a carrier to deny or limit access to medical treatment that would be readily available to someone with a different diagnosis.


Additionally, if a health service is ordinarily exclusively available to an individual of a particular gender, that service will be provided when it is necessary or appropriate. It is unlawful to refuse to cover gender-specific treatment because an individual is a different gender than listed in their insurance documents or sex assigned at birth. This is important because denials based on “mismatched” gender information have typically obstructed access to preventive services that are commonly associated with only one gender such as mammograms or prostate exams.


Further considerations


Submitting documentation and navigating this system will be necessary to accessing care. Medicaid will require documentation from medical providers that is consistent with World Professional Association for Transgender Health (WPATH) criteria in order to extend coverage for transition-related procedures. Because this change is so new, it is difficult to anticipate exactly how the process will function, but Mazzoni Center has many different types of professionals qualified to assist in navigating the new system.   


If you have questions or would like to discuss Medicaid coverage further, please speak to your Mazzoni Center provider or contact Mazzoni Center Legal Services at [email protected] or 215-563-0657.   

  • For a PDF copy of the CHIP transmittal, click here
  • For a PDF of the PA Medical Assistance Bulletin, click here.

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