Help Transgender Patients Understand Regulations that Affect Gender Care Rights and Coverages

Original story posted on: March 9, 2020

Many insurers are not experienced in processing claims for transgender patients.

When the Patient Protection and Affordable Care Act (PPACA) went into effect on July 18, 2016, Section 1557 included a provision that prohibited most health insurance plans from discrimination based on gender identity and transgender status, under the category of sex discrimination. Section 1557 provides protection when questioning the LGBTQ population, as well as provides protection to patients based on race, color, sex, age, and disability.

HIPAA, the Health Insurance Portability and Accountability Act, also requires medical providers and health insurance plans to protect patient privacy when it comes to certain information and details about health and/or medical history. Information about transgender status, including but not limited to diagnosis, medical history, and sex assigned at birth or anatomy relating to gender dysphoria data collection, is considered protected health information (PHI). As with routine HIPAA privacy standards, this information also falls into the category of information that should not be shared with anyone without the patient’s written consent. As far as disclosing this information to other staff within the clinical practice, it should not be shared unless there is a medically relevant reason for that staff member to know. This could be considered a HIPAA violation if shared without patient consent.

Insurance plans also have coverage rules they must follow when providing benefits for transgender patients. The Transgender Healthcare State Maps of Laws and Policies that can be found on the Human Rights Campaign’s website ( ) states:

  • Zero states provide transgender-inclusive health benefits for state employees (although 13 states, including California, Connecticut, Delaware, Maryland, Massachusetts, Minnesota, Nevada, New York, New Jersey, Oregon, Rhode Island, Vermont, and Washington, ban exclusions for state employees).
  • However, six states ban exclusions for transgender healthcare, universally.

Also, most LGBTQ health centers provide wellness programs and services, HIV/STI services, and counseling services, with only 10 percent of the centers providing transgender care, pharmacy, services or psychiatric services. These centers have also been found to be mostly cash pay clinics, not set up for insurance payments.

Since most of us are insured through our employer, many of the larger employers can negotiate their coverages to include and exclude certain services and specific care. General transgender coverage is not a legal exclusion, but transgender procedure coverage can be an optional coverage, since this is largely considered elective surgery.

Another issue that has arisen is that many insurers are not experienced in processing claims for transgender patients, and this can be problematic with automated systems. For example, if the patient is designated as “female” in the electronic medical record (EMR) and billing system, but the treatment being billed or pre-authorized is for gender-specific male anatomy, you will see claim denials and delays, and/or denials for treatment.

Now, what is important to know about exclusions is that an insurance company cannot automatically exclude a specific type of procedure for a transgender patient if that procedure is a covered service for a non-transgender patient. Claims may be automatically denied when the “gender markers” do not match, meaning that a claim was filed for a specific service traditionally only provided to gender-specific patients, and now this claim is being sent for the opposite gender. To serve this population of patients, providers need to be clearer in their clinically relevant representations of the patient when documenting in the EMR, so that the RCM staff can be clear to the insurance plans when dealing with and educating them on pre-authorizations, claim submission, and payor denials.  

The bottom line is that you, as a provider, still need to provide medically necessary documentation support when performing procedures relating to gender reassignment surgery. Depending on the health plan, some of these procedures were previously considered cosmetic or experimental.

Now, in 2020, with the new ICD-10-CM updates to the Gender Dysphoria (F64.8) condition, more insurance plans are providing coverage. It is up to your practice to understand the importance of quality data collection and how it can affect reimbursement, access to insurance coverage, and benefits for this patient population if clinical documentation integrity is not a top priority.

Programming Note:

Listen to Terry Fletcher report this story live today during Talk Ten Tuesday, 10-10:30 a.m. EDT.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

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