Major advance in LGBT health care yields more questions

Fact No. 1: LGBT Coloradans cannot be denied health care coverage if their provider is based in Colorado.

Fact No. 2: No one is exactly sure what’s covered.

What’s happened is this: On March 19 the Colorado Division of Insurance, the state’s insurance regulation arm, issued a bulletin stating discrimination in health coverage based on sexual orientation and transgender status is prohibited.

But as simple as the directive may be, what’s at odds is hundreds, if not thousands, of private health insurers’ specific policies that have been established for decades, gender–biased digital coding for medical treatment that routinely flags and denies insurance coverage, and the behemoth bureaucracy of Medicare and Medicaid.

And just as LGBT activists here are celebrating a major milestone, they’re asking the LGBT community to have patience as they expect more questions and confusion to surface while insurance companies and health providers work through uncharted territory on what is likely to be a case–by–case situation.

Take Robin Christian for example.

After transitioning eight years ago, Christian had to make the decision whether he would continue to identify as female to have his annual pelvic exam covered by insurance or change his gender marker to male to have his testosterone taken care of.

To complicate matters, before transitioning, Christian, who now lives in Aurora with his boyfriend Matt Gale, was diagnosed with endometriosis. Cells from the lining of his uterus grew in other areas of the body. He suffered excruciating pain including irregular bleeding.

His doctor put him on narcotics for weeks and he had to quit working.

Eventually, he and his health care provider decided a hysterectomy was the best solution. But Christian’s insurance company initially flagged the request to pay for the surgery because a matrix established by his insurance company to track fraud determined it wasn’t medically necessary for a man to have a uterus removed.

Christian followed up with the company, and after he explained his trans status, the surgery was covered. And while Christian said the company was “super reasonable and professional,” he hopes the new state directive will inspire insurance companies to incorporate mechanisms to tracks transgender people’s medical history to eliminate potentially uncomfortable conversations.

“I had to do all of my own research,” he said. “It should be the other way around.”

Courtney Gray, transgender program coordinator at the GLBT Community Center of Colorado, said it’s going to take more people like Christian to make the health care system better.

“We need to challenge these policies directly,” she said during a town hall meeting discussing changes to the health care system in Colorado. “That’s how it’s going to be changed. There are no clear guidelines as to what’s being covered yet. The marketplace is going to change a lot.”

Gray said if a medical request is denied, patients should start with an appeal to their insurance company. Once that process is finished, if a patient still believes they are being discriminated against they should file a complaint with the state’s civil rights division that regulates Colorado’s nondiscrimination laws.

For Grey and Ashley Wheeland, health policy director for the states’ largest LGBT advocacy organization One Colorado, the bulletin, coupled with the Affordable Care Act, also known as Obamacare, is going to open up more options – especially for trans Coloradans.

Admittedly, protection for trans people is not explicitly spelled out in the health care reform law. But Obamacare, Wheeland said, forbids discrimination on two principles that should directly protect trans people. The first bans discrimination based on health conditions, like gender identity disorder or dysphonia. The second bans discrimination based on protected classes including “sex.” Several government interpretations of “sex” include gender variance.

And as lawmakers, activists and lawyers are working on one front to make sense of the policies, another area of focus is the medical provider working directly with LGBT patients. It will be those first conversations between doctors and patients on what is and is not medically necessary that could determine what insurance companies will pay for.

In Christian’s case, had his doctor not said the surgery was medically necessary, the insurance company most likely would never had considered it.

For trans people, these conversations and policies will be especially vital when discussing either top or bottom surgery with their providers. Currently most insurance companies consider top and bottom surgery’s elective procedures. However, Gray points to a growing number of health officials who are speaking up saying some surgeries for trans people are medically necessary to improve their physical and mental health.