The Benefits of Equality:

A Blueprint for Inclusive Health Care for Transgender Workers

Second Edition

Thank you
Basic Rights Education Fund would like to thank the following individuals and organizations: Production The volunteer leaders who created and edited this toolkit: Sasha Buchert, Cass Cole, Ray Crider, Devon Goss, Rowan Everard, Kirsten Keith, Kerry Johnson, Cameron Mathews, Joe LeBlanc, Sue Orchard, Alex Pakula, Lisa Summers, Adrien Wolmark, and Maxwell Zach. Alejandro Juarez, for designing the toolkit. Content Leaders at the City & County of San Francisco, the City of Portland, and Multnomah County for sharing their data and experience as employers providing inclusive health care. Debby, Ray Crider, Peter Dakota Molof, Leigh Dolin and Adrien Wolmark for sharing their personal and professional accounts of the need for inclusive health care. The Human Rights Campaign Foundations Workplace Project for giving us permission to adapt for use in this guide the material contained in their resource Transgender-Inclusive Health Care Coverage and the Corporate Equality Index. The original HRC resource can be downloaded at www.hrc.org/transbenefits. Partners TransActive Education and Advocacy for their partnership in increasing access to health care for transgender children and youth. Transgender Law Center for their partnership and contributions to the work for inclusive health care. The National Center for Transgender Equality, the National Gay & Lesbian Task Force and the Williams Institute for their continued leadership for equality and justice for transgender communities across the US.

Special thanks to Moda Health for sponsoring the printing of this edition.

This toolkit was authored and compiled by Basic Rights Education Fund. For information about reproducing these materials, contact us at 503-222-6151. Available electronically at www.basicrights.org/resources/ Primary authors: Aubrey Harrison, Program Director, and tash shatz, Trans Justice Program Manager

Basic Rights Education Fund and transgender-inclusive health care

For nearly two decades, Basic Rights Oregon has championed equality for lesbian, gay, bisexual and transgender Oregonians. Among our top priorities is ensuring that transgender Oregonians have access to the medically necessary health care they needhealth services which many of us take for granted, yet are routinely denied to our transgender co-workers because of categorical exclusions written into most insurance policies. ln 2009, Basic Rights Oregon convened its Trans Justice Working Group, a group of transgender, genderqueer, gender nonconforming and allied community leaders to identify priorities in their community. These leaders conducted extensive community outreach through in-person forums and online surveys. What they learned from Oregons transgender community was astonishing: From being denied medically necessary care like hormone treatment, to being refused coverage of routine annual exams and life-saving cancer screenings, discrimination was having a profound impact on the lives of transgender Oregonians every day. But things are beginning to change. Historically, Oregon businesses have led the way by providing workplace protections against discrimination and protecting families by ensuring domestic partnership benefits, and now Oregon businesses are leading the way again by ensuring that transgender employees have the same access to medically necessary healthcare that their co-workers receive. These businesses know that providing all workers with the medically-necessary care that they need is not just good for workers and their families, it is also good for business. Providing competitive benefits attracts the best and brightest, it ensures that workers are healthy and productive, and it lives out the values of equality and inclusion in the workplace. Transgender-inclusive health care makes good business sense. The tide is shifting nationally, and Oregon is again at the forefront of equality. ln 2010, Multnomah County removed transgender-specific exclusions from its health care benefit coverage; followed by the City of Portland in 2011. In 2012, the number of businesses who removed discriminatory exclusions from their health plans nearly tripled. Today, 25 percent of Fortune 100 Companies and many Oregon businesseslarge and smalloffer inclusive health care to all workers. And most recently, we saw our biggest win yet: in December 2012 Oregons insurance division banned discrimination against transgender people in most of the states private insurance plans. This toolkit is designed to provide business leaders, workers, and union members all the tools you need to put your values into actionvalues like dignity, equality, and fairness. Removing exclusions targeted at transgender people is a critical way to ensure that these values are being realized. Equality strengthens businesses by providing safe, welcoming, and healthy workplaces. Oregon businesses and unions not only drive our economy and creative industries in countless ways, they are also at the forefront as advocates for gay, lesbian, bisexual, and transgender Oregonians. And that makes our families, our communities, and our state stronger for all Oregonians. With your leadership, transgender Oregonians can truly experience equality in the workplace, by gaining access to the same health care their co-workers rely on every day. Together, we can make Oregons workplaces stronger and more equitableand that benefits all of us. Dont forgetwere here to help and we look forward to working with you! Please contact us any time at 503-222-6151.

Jeana Frazzini Executive Director Basis Rights Education Fund and Basic Rights Oregon

Table of Contents
1. 2. Why transgender-inclusive health care?

Step one: Starting the conversation

Identifying and engaging decision-makers Sharing your story What transgender-inclusive health plans look like Sample letter for your insurance provider

3. 4. 5.

Step two: Assessing your benefits plan Step Three: Talking to your insurer Frequently Asked Questions

Appendix Introductory materials

Key terms and phrases used in this toolkit Health Care Plans 101 Just the Facts: Ending Gender Identity Discrimination in Health Insurance

Medically necessary care

Handout: transition-related care is medically necessary American Medical Association resolution American Psychological Association resolution Medically necessary services, model insurance plans, and standards of care

Affordable to provide

Handout: cost data on providing coverage IRS ruling on transition-related care City and County of San Francisco memo on cost City of Portland memo on cost

Multnomah County memo on cost Port of Portland memo on cost National College of Natural Medicine memo on cost Oregon Health and Science University memo on cost California Economic Impact Assessment report

Good for the Workplace

List of Oregon businesses that provide inclusive care List of national businesses that provide inclusive care List of colleges and universities that provide inclusive care

Oregons Insurance Bulletin Banning Discrimination

About the bulletin Filing complaints with Oregons Insurance Division Personal stories from individuals

Personal impact: a small change, a big difference

Personal stories from medical providers

Additional resources

Transgender health care advocacy resources

Making the most of this toolkit

Whether youre just beginning to think about this issue or your workplace has considered it for years, theres something in this toolkit for you. If youre beginning the process of advocating for these benefits at your workplace, start at the front of the toolkit. Youll learn more about the issue and then asses who makes these decisions at your workplace. After that, you can assess your benefits plan before talking to your insurer. And you can utilize the Frequently Asked Questions and appendix materials along the way. If youve already explored some of these issues at your workplace or are looking for specific information, you can find many resources that are easy to photocopy in the appendix. This toolkit is available electronically at: www.basicrights.org/resources/

Why transgender inclusive health care?

We all know someone who has been denied medically necessary care by an insurance company working to protect its bottom line. Its unfair, painful, and downright dangerous when it happens, and it happens all too often. Many Oregonians continue to experience discrimination by insurance companies and health care service plans on the basis of gender, particularly members of Oregons transgender community. Most insurance plans specifically exclude critical health care for transgender Oregonians. This includes both transition-related care like hormones, surgery and counseling; and sex-specific care like cancer screenings and reproductive health care. This is medically necessary care thats regularly provided to non-trans Oregoniansand its being denied to transgender Oregonians solely because of their gender identity.

Affordable to provide coverage

No jurisdiction, employer, or insurance company which covers trans health care has found the cost to be prohibitive. In 2011, the City of Portland determined that the cost increase was only .08% of its health care insurance budget. Multnomah County has seen low utilization since 2011. The City and County of San Francisco have provided comprehensive coverage for years with research showing no discernible cost. More information available on page 38 of appendix.

Medically necessary

An increasing consensus has emerged among medical and mental health professionals affirming the need for adequate access to health care coverage for transgender people. Organizations that have affirmed transgender health care as medically necessary and/or have affirmed that it is an act of discrimination to deny health care to transgender individuals include:
The American Medical Association The National Association of Social Workers The American Psychological Association American Association of Clinical Endocrinologists American College of Obstetricians and Gynecologists The World Professional Association for Transgender Health American Psychiatric Association Oregon Department of Consumer and Business Services California Department of Managed Healthcare Colorado Division of Insurance Washington, D.C. Department of Insurance, Securities, and Banking Vermonts Department of Financial Regulation Division of Insurance Municpalities including the Cities of San Francisco, Portland, Seattle, Berkeley, and Philadelphia.

See appendix for full text of select resolutions.

Good for workplaces

Dozens of Oregon businesses have removed exclusions from their insurance plans. These businesses know that offering equal and inclusive health care benefits creates an environment where all workers feel valued and can bring their whole selves to the workplace. To promote innovation and creativity, and to compete in the marketplace, companies understand the need to embrace and advance diversity and inclusion. Removing discriminatory barriers within insurance plans and providing trans inclusive health care benefits is a concrete demonstration of that commitment to fairness and inclusion. Examples of Oregon businesses offering inclusive care include: Alcatel-Lucent American Express Ameriprise Financial Bank of America Chrysler Motors Davis Wright Tremaine Kimpton Hotel & Restaurant Group Kraft Foods Microsoft New Seasons Market Oregon Health & Science University (OHSU) Port of Portland State Farm Stoel Rives

Step one: Starting the conversation

Identify your decision-makers
In order to move the conversation forward about inclusive health care in your workplace, youll need to know who makes decisions about what is and isnt included in your workplaces benefits plan. Business decision-makers. Each company is different, so theres no standard answer to who makes decisions about workplace health benefits. First, identify the person within your company who primarily manages your companys benefits and relationship with your insurer. Often, this will be a benefits manager, human resources director, or other human resources staffer. Next, make sure you understand the process that that person goes through to approve changes to the insurance plan. In some cases, this person will simply propose changes to the Chief Financial Officer or business owner, who can approve or deny the changes. In other cases, a more involved process may include engaging workers or management for feedback. Either way, its important to understand who has input, at what levels, and when. That way, you can engage the right mix of people in the conversation about assessing and shifting your benefits plan. Union decision-makers. Similarly, while many unions have similar structures, not all unions are the same. Important starting points within your union could be your union steward, members of your bargaining team, or a staff organizer, if you have one.

Talk about the issue

For transgender people and allies alike, figuring out where to begin a conversation about the importance of transgender coverage can be a challenge. Starting that conversation within your business or union is the first step in assessing and expanding your benefits, and its a good opportunity to hone your approach to discussing the need for transgender-inclusive health care. Here are some tested approaches to talking about transgender-inclusive health care: Make the case. There are plenty of important reasons to support transgender-inclusive health care, many of which are encapsulated in three key points: Its medically necessary. Doctors, medical associations, advocates and patients agree that transgender-inclusive health care, including care related to gender transition, is medically necessary treatment. Its cost effective. Independent studies and real-world experience in public and private sectors conclude that the cost of covering transgender-inclusive health care is negligible. The cost is often small enough to be declared de minimis (so minor as to merit disregard), and requires no increase in cost to insured individuals.

 Its the right thing to do. We all know someone whos been denied the health care they need - and it happens all too often within transgender communities. Exclusions keep transgender people from accessing care that non-transgender people receive on a regular basis - and that care is denied solely because of their transgender identities. Removing exclusions and providing coverage for inclusive care are small changes that can make a big difference in the personal and professional lives of transgender workers - and it reflects your companys commitment to inclusion, fairness, and diversity. Share the evidence. Major health care and government institutions support transgender-inclusive health care. The American Medical Association, the American Psychological Association, and even the IRS tax court have affirmed the medical necessity of transition-related health care. See the appendix of this toolkit for the original text of supportive resolutions from these organizations and more. Share your story. If you feel safe and comfortable in sharing your personal story, it can be helpful in moving your colleagues to support. Whether you need transition-related care for yourself, a family member or friend, or youre an ally to transgender communities, sharing your personal motivation to support transgender-inclusive health care can help connect others to theirs. Find a template for this on page 8. And for more approaches to starting this conversation, see the health care fact sheet on page 24 of the appendix.

Engage your decision-makers

Now that youre grounded in who to talk to and how to discuss the need for inclusive health insurance, its time to start the conversation with your benefits manager, human resources department, or union. Email or call this decision-maker and ask to set up a phone call or short meeting to start the conversation. As part of this conversation, youll want to connect, context, and commit. If you dont know this person well, be sure to connect on a personal and professional level. Then, provide context by sharing your interest in removing exclusions from your workplace health plan. This is your opportunity to talk about the issue, as outlined above. Remember: this care is medically necessary, its cost effective, and its the right thing to do. When you talk, be sure to gather answers to the following questions: Does our insurance plan currently cover health care for transgender workers, including coverage related to gender transition? Are there exclusions in place that would restrict or prohibit coverage for transgender workers? If this is unknown, what next steps can we take to assess our plan with our insurance agent or broker?

 Has our company made a commitment to the inclusion and support of lesbian, gay, bisexual, and transgender workers? Does our current insurance policy reflect that commitment? Is there an employee resource group or union caucus who should be engaged in this conversation? What processes exist to change insurance benefits? Who needs to be engaged in that process? Are there specific annual deadlines associated with that process? What role can the decision-maker play in moving forward with a process to assess the workplace insurance plan, remove exclusions, and ensure coverage of care? Who else will they need to engage in that work? How can you help? Close your conversation with a commitment. What next steps will this decision-maker commit to taking? What can you do to help? Then, set a time to follow up on your agreed-upon next steps to move the process forward. For help figuring out how to engage your decision-makers or talk about the issue, call Basic Rights Education Fund at 503-222-6151. Were here to help!

Sharing your story

Personal stories are one of the best ways to convey the importance of transgender-inclusive health care. Since transgender people may not wish to share their identities (and may face discrimination if they do so) make sure to get explicit permission before sharing another persons name or personal information. Here is a template for sharing your story: 1. Introduce yourself, including your position and how long youve been with your employer/ union. 2. Share why the issue matters to you. Do you have a partner, family member, friend, or co-worker whos transgender? Do you personally identify as transgender? Or do you see this as part a larger effort to achieve equality and end disparities in access to health care? Whatever the reason, share that as part of your story. 3. Share a story. It could be something thats happened to you, or something thats happened to a friend or family member. It could be one of many common examples of health care discrimination in your benefits plan. Here are some examples: Our benefits plan specifically excludes care for transgender individuals, so my transgender co-worker is unable to access the same hormones as a woman going through menopause can. The specific exclusions in our benefits plan led to annual reproductive health exams being denied to my co-worker. It is important to me to work for a business/belong to a union that works to end discrimination in the area of access to health care for transgender individuals. 4. Convey how these exclusions affect your experience as a worker. For example, Its important to me that all of my co-workers receive the same quality of care as I do. 5. Identify a solution: Removing discriminatory language from the benefits plan and ensuring that everyone can access care equally. For example personal stories and stories from medical professionals see appendix.

Step two: Assessing your benefits plan

Adapted from the Human Rights Campaign Foundations Transgender-Inclusive Health Care Coverage and the Corporate Equality Index www.hrc.org/transbenefits
Most U.S. health insurance policies have exclusions listed on transition-related careright alongside those for cosmetic or experimental careeven though treatment of gender identity disorder is neither cosmetic nor experimental. Transgender-based exclusions have been written broadly enough to exclude health care coverage completely unrelated to the process of a gender transition, for example, medical treatment for migraine headaches or gynecological exams for transgender-identified men. Claims for unrelated basic care (e.g., for a cold, flu, or a broken arm) have been denied when carriers learn of transgender status. In addition, coverage denials often extend to exclude a broad range of pre- and post-transition care across the patients lifespan (e.g., prostate or pelvic exams, blood tests, or prostate, breast, ovarian, or uterine cancer-related treatments). Exclusions may also be carved out to avoid covering certain transition-related treatments: for example, the mental health diagnosis of Gender Identity Disorder may be covered, but none of the medically necessary follow-up care would be (e.g., hormone replacement therapy, surgical procedures, follow-up visits, etc). Transgender individuals have medical needs similar to those of any other individual. While the medical process of sex affirmation/reassignment may seem unfamiliar or strange to many, these services are critical to the health of the individual who needs them. Examine the wording of your plans transgender exclusions clause to understand if the clause is so broad that it: Presents barriers to coverage for non-transition related treatments; Negates coverage outright for all transition related care; Offers partial coverage for transition-related care (hormone therapy but no surgical procedures, for example). This will give you an understanding of what your plan is already covering and to what extent sweeping, versus more focused, efforts need to be made to eliminate the exclusions. These are examples of actual transgender exclusions in health insurance plans. The effects of these exclusions can vary depending on carriers interpretations. For example, any of the first three examples could be narrowly implemented to exclude only the surgical aspects of sex affirmation/reassignment,

How to Identify Exclusions

but each have also been used to deny a much broader range of care, including routine annual exams and other services unrelated to transition: Services for, or leading to, sex transformation surgery. Gender Transformation: treatment or surgery to change gender including any direct or indirect complications or aftereffects thereof. Expenses for, or related to, sex change surgery or to any treatment of Gender Identity Disorders. Transsexual surgery including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. Removing transgender exclusions is still not enough to ensure that inclusive coverage will be available for workers and dependents that require medically necessary care. Once exclusions are removed, a truly inclusive plan will also affirm available coverage for Gender Identity Disorder. Clearly articulated written standards that affirm and spell out provisions of effective treatment are often necessary for rare conditions where medical expertise is correspondingly rare, where experts are geographically separated, and especially where the condition being treated is the subject of intense social stigma and misperception. Advocates for inclusive health coverage have found a number of helpful tools for negotiating and establishing transgender-inclusive coverage. Employers that are concerned about adding transition-related care are often road-blocked by common misconceptions and a lack of understanding around transgender identity. Implementing inclusive care is especially difficult when the insurance companies that do provide some form of coverage for transition-related care are still not fully meeting the medically necessary needs for workers.

What Transgender-Inclusive Health Plans Look Like

A key feature of every inclusive health plan is, of course, the removal of explicit exclusions of transitionrelated health care. But beyond removing exclusions, what do we need to cover in order to be truly inclusive? All transition-related health care services that are medically necessary as determined by a patient in consultation with their physician should be covered, including, but not limited to consultation, follow up, and repair (if necessary). All deductibles, co-pays, benefit maximums or other restrictions should be commensurate with those offered to non-transgender individuals. Medical leave for transition-related care should be applied in the same manner as leave for any other medical treatment. For samples of inclusive plans and lists of procedures to cover, see page 33 in appendix.

Recommendations for Transgender Health Care

Prepared by Jody Marksamer and Dylan Vade, Transgender Law Center That medical providers recognize that there is great diversity among transgender people and provide the care that is best suited for each transgender individual, based on the individuals own needs and choices. Health care providers often do not treat transgender people respectfully or appropriately. There should be mandatory transgender education for all medical students and for all health care providers. That insurance companies recognize that there exists great diversity in bodies; that insurance companies cover every person holistically and completely; that insurance companies not require people to check male or female boxes.

10

Step three: Talking to your insurance provider

A critical step in attaining an inclusive health insurance plan for workers is starting a conversation with your insurer to assess whats included in your current plan and whats not. These conversations are opportunities both to assess the state of your current plan and to express your interest in an inclusive plan to your insurer. To hold the most effective conversation, we recommend a few best practices. Get the right people on the phone. In order to have a focused conversation about your insurance plan, its important to ensure that the people who best understand that plan are in the room. For businesses, this usually means a benefits manager or human resources staff member - whoever directly manages workplace benefits and the relationship with your insurer. For unions, this may mean a union steward or a member of your bargaining team should get in touch with human resources staff to coordinate these questions. Its also important to ensure that your contact at the insurer has handled your company or employers account in the past. Usually, the best person to move this conversation within your insurer is the account representative or insurance broker your company has used on an ongoing basis. Ask precise questions. Asking clear, specific questions is critically important, both for you and for your insurer. Since so many insurance plans exclude transition-related health care as a matter of course, even those who administer and purchase the plan may be unaware of the specific levels of exclusion or coverage available to workers. Be prepared to ask about specific treatments, diagnoses, and the conditions under which coverage is provided or denied. Utilize recommended questions. Specific, precise questions will help you and your insurer quickly assess the level of coverage afforded to workers under your current plan. Here are a few questions to start the conversation: Does our companys current insurance plan include a statement specifically excluding transition-related care from coverage? (Exclusions may be worded to rule out coverage of surgical procedures in particular, may exclude treatment of Gender Identity Disorder, or may broadly exclude any treatments, services, or procedures related to gender transition.) If so, can we remove this exclusion from our current plan or purchase a plan that does not contain an exclusion? Does our companys current plan cover mental health care for transgender individuals,

11

including treatment for Gender Dysphoria or Gender Identity Disorder? If so, what level of coverage is available and what caps apply? Does our companys current plan cover hormone therapy for transgender individuals for the purposes of gender transition? If so, under what conditions? What level of coverage is available and what caps apply? Does our companys current plan cover surgical procedures for transgender individuals for the purpose of gender transition? If so, which procedures? What caps apply to this coverage? Follow up. After speaking with your insurer, engage human resources staff, your benefits manager, or leaders in your union in a conversation about what to do next. If your plan includes exclusions or restrictive caps on coverage, next steps could include any of the following: Gathering information on insurance plans available through other insurers and assessing your options for changing insurers Engaging your bargaining team in a conversation about ensuring the inclusion of transgender-inclusive health care in your benefits plan Writing to your current insurer to formally request the removal of exclusions, or the increase or elimination of caps on care

12

Sample letter for your insurance provider

Dear [broker/agent], As part of this years reassessment of our companys insurance needs, we have some questions about the availability of medical and mental health care related to gender transition for transgender individuals. We are highly interested in purchasing an insurance plan that meets the needs of all of our workers, including transgender workers, and it has come to our attention that our current plan may include exclusions or other barriers. To begin this conversation, we would like to better understand the benefits available under our current plan. Please respond with answers to the following questions: Is our companys current insurance plan in compliance with Oregon Insurance Division Bulletin INS 2012-01*, which clarifies insurers obligations to provide equitable coverage to transgender people under Oregon law? Does our companys current insurance plan include a statement specifically excluding transition-related care from coverage? (Exclusions may be worded to rule out coverage of surgical procedures in particular, may exclude treatment of Gender Identity Disorder, or may broadly exclude any treatments, services, or procedures related to gender transition.) If so, can we remove this exclusion from our current plan, or purchase a plan that does not contain an exclusion? Does our companys current plan cover mental health care for transgender individuals, including treatment for Gender Dysphoria or Gender Identity Disorder? If so, what caps apply to this coverage? Does our companys current plan cover hormone therapy for transgender individuals for the purposes of gender transition? If so, under what conditions? What caps apply to this coverage? Does our companys current plan cover surgical procedures for transgender individuals for the purpose of gender transition? If so, which procedures? What caps apply to this coverage? Do the treatments and level of coverage available reflect the standards of care set forth by the World Professional Association for Transgender Health, the industry standard for providing care to transgender individuals? If any of this coverage is unavailable under our current plan, what other plan could we purchase from you that would include this care?

13

As a longstanding account, meeting the health insurance needs of our workers is deeply important to us. If this care is unavailable, we request that you provide the care that our workers need. Transition-related care is critically important for transgender workers. Treatments like hormone replacement therapy, counseling, and routine surgical procedures (like mastectomies) are regularly covered for non-transgender workers, but are often denied to transgender workers solely due to their gender identity. Additionally, this care has been affirmed by the American Medical Association, the American Psychological Association, the World Professional Association for Transgender Health, and even the IRS tax court as being medically necessary care for transgender individuals. As a company that values diversity and supports lesbian, gay, bisexual and transgender equality, we seek to reflect that commitment in all aspects of our work. We look forward to your response, and hope to work together to identify a plan that meets our companys needs. Thank you in advance for your time, attention and prompt response. Sincerely, [Signature and title]

*The bulletin can be found online at: http://www.cbs.state.or.us/ins/bulletins/bulletin2012-01. html. Note that Insurance Division bulletins do not govern plans for self-insured businesses, public insurance plans (like the Oregon Health Plan), or ERISA-governed employers. All other plans in Oregon, however, are subject to the bulletin.

14

Frequently asked questions

Adapted from the Human Rights Campaign Foundations Transgender-Inclusive Health Care Coverage and the Corporate Equality Index www.hrc.org/transbenefits.

Why should we be covering this? Isnt it a choice to change genders?

Numerous medical and allied health associations are now calling for insurance coverage of transition-related care. Associations with resolutions or statements on this issue include the American Medical Association, American Psychological Association, National Association of Social Workers, American College of Obstetricians and Gynecologists, and World Professional Association for Transgender Health, among others. Transgender-inclusion is not about a new and different set of services. Transgender-inclusive health coverage is part of equal compensation and specifically equal benefits.

No transgender people work here who would benefit from this?

Transgender people are part of most workplaces. People dont always share their identities because of factors including pervasive stigma and discrimination, as well as personal choice and privacy. Workers who are not transgender may have partners or dependents who need to access these services.

How many transgender people are there?

Many local, state, and federal agencies do not accurately count transgender peopleor count them at all. As such, data on transgender individuals in the United States is relatively sparse. Some trans people may not identify as transgender, may consider their identities private, and/ or may be afraid to disclose their gender identity, so even given the opportunity to indicate this on a form, they still may not choose to do so. Prevalence estimates on transgender individuals vary widely, ranging from 0.2% to 1.0% of the population. For this population, access to inclusive health care is a small change in their workplace health plans but it can make a big difference in their health and well-being.

Are these cosmetic surgeries? We dont cover those.

This care is medically necessary and reconstructive, not cosmetic. This treatment is provided by health professionals in accordance with the World Professional Association for Transgender Healths Standards of Care.

15

Surgical reconstruction can restore physical structures of the bodies to those which reflect the internal experience of the individual (and which are generally considered normal for any woman or man.) Although someone may live socially as a woman or man regardless of surgery, the physical component of treatment can be crucial to internal congruence and self-affirmation.

What types of services and procedures are medically necessary parts of sex reassignment?
Some examples include: Hormone replacement therapy Estrogens (also androgen blockers) and testosterone Puberty blockers Mental health services Surgical reconstruction See a full list on page 33 in the appendix. Breast/chest reconstruction Facial reconstruction Gonadal surgery Genital reconstruction Other procedures or services Hair removal (electrolysis) Speech therapy

Wont these changes to our plans be very expensive?

No jurisdiction, employer, or insurance company which covers transition-related health care has found the cost to be prohibitive. Distributed costs are extremely low and the annualized costs to the employer of providing insurance coverage for transgender-related care are typically negligible. See page 35 in appendix for more information. The best available public data on insurance coverage experience is from the City and County of San Francisco. With 25-30,000 employees (and 80,000 plan members), actuaries estimated that 35 people per year would access $50,000 in services each. The City and County released their cost analysis in 2007, after seven years of experience: Initially, they charged $1.70 per employee per month (PEPM), as dictated by their cost estimate. After three years, they had gathered $4.3 million, and paid out just $156,000. Then, they lowered their PEPM cost, and paid out even less: $44,118 for 19 claims. In 2007, they finally declared the cost de minimis and stopped pricing care separately. Additionally, not all transgender people access transition-related care like surgery and/or hormones. One frequently cited estimate is that one in 240,000 people in the US access transitionrelated surgery each year1. In 2011, results of a groundbreaking survey were released by the National Center for Transgender Equality and the National Gay and Lesbian Task Force2. Nearly 1. http://www.tgender.net/taw/thb/THBPrevalence-OE2008.pdf 2. http://www.thetaskforce.org/downloads/reports/reports/ntds_full.pdf

16

6,500 transgender respondents reported that at least 18% had already accessed some type of surgical care, while 50-60% of people surveyed wanted to one day access the most common procedures.

Our insurance carrier representative has told us that few if any plans ever cover services for sex reassignment. Is this true?
While historically this may have been true, over the last decade an increasing number of insurance plans have recognized the need to eliminate these discriminatory exclusions. Today, many insurance carriers large and small have written policies on transition-related care, and are administering plans for a variety of employers. Still, many individual sales representatives may be unfamiliar with this area of coverage, and information may not be readily available from the carrier. Let your carrier representative know that a growing number of plans do cover these services, and if your carrier is listed below, assure them that their company has experience with this.

What carriers are administering plans with coverage of sex reassignment surgeries and procedures?
Most major insurance carriers, including the entire following list, are administering or insuring coverage for at least one employer or student plan. Aetna AmeriHealth Caremark Cigna EmblemHealth (GHI, HIP, Vytra) Harvard Pilgrim Health Net HealthPartners Humana Kaiser Permanente Medica MedicalMutual of Ohio MVP Health Care Nationwide ODS UnitedHealthcare Oxford Blue Cross Blue Shield, some affiliates, for example: BCBS Illinois Premera Blue Cross BCBS Michigan BCBS Massachusetts BCBS Minnesota BCBS North Carolina Blue Shield of California HMSA Horizon BCBS Independence BCBS WellPoint subsidiaries (Anthem BCBS)

17

We never list out every treatment that is covered by our plan. Why do we need to explicitly state coverage here?
Insurance contracts are typically not readily available or accessible to workers, especially prior to enrollment. As a result, employers that have modified their insurance contract to remove discriminatory insurance exclusions against transgender people from their health insurance plans need to communicate to workers (and their dependents) that transgender-inclusive coverage is available both when the benefit first becomes available and on a regular basis. In order to respect workers privacy, the availability of a transgender-inclusive insurance option should be communicated widely to avoid forcing workers to out themselves as transgender in order to determine whether they have coverage.

Which other employers are currently offering transgender-inclusive health plans?

Over 200 employers rated in the 2012 Corporate Equality Index are offering transgender-inclusive health coverage (see page 47 in appendix). And 25% of Fortune 100 companies currently cover this care. In addition, numerous public employers are known to offer inclusive coverage. These include the University of Michigan and the entire University of California system, the cities of Seattle, Minneapolis, New York, San Francisco, and Portland, as well as Multnomah and San Francisco Counties.

We are self-insured. Cant we just cover individual health costs on a case-by-case basis?
These types of solutions pose issues for medical privacy. Direct reimbursement structures require the individual to disclose the precise nature and cost of these services, which may reveal profoundly sensitive or personal information. With few exceptions, employers do not need to know about a transgender workers specific medical treatments beyond planning for potential medical leave for transitioning workers. The privacy of a transgender partner/spouse or dependent child of a worker must be similarly respected. In order to respect the workers or dependents privacy, coverage for services should be handled as any other medical service would be, through the plan administrators claims process, which safeguards individual information from the workplace. Similarly, the availability of a transgender-inclusive insurance option should be communicated widely, especially in the open enrollment process, to avoid the need for a worker to out themselves or a dependent family member as transgender in order to access care.

18

Should we expect a premium increase if we eliminate the transgender exclusion and start covering all medically necessary procedures related to sex reassignment?
In national interviews with the Human Rights Campaign, employers that provide this coverage have all reported minuscule or zero initial premium increases associated with this specific area of coverage. Moreover, no employers that provide this coverage have indicated subsequent increases based on utilization, as reported utilization has been extremely low, with few claims and low costs. This includes employers of very different sizes ranging from 500 to 100,000+ employees. Premium pricing can differ, however, based on specific circumstances, such as the size of the employer and the insured pool, structure of coverage, or other factors.

Our insurance carrier representative has responded with a proposal which includes a significantly increased premium. How can we respond to this?
Premium increases are based on predictions of future utilization and claims costs. Very often premium increase estimates above minimal levels have been traced to erroneous assumptions regarding the possible number of transgender individuals who will require services each year, as well as inflated notions regarding the extent or cost of such services. Ask your representative to provide more information regarding the basis for their cost predictions. A simple check may reveal such basic errors as assuming that every transgender worker will require every phase of transition-related care, including all available surgeries on an annual basis. Basic Rights Oregon staff or a consultant with specific area expertise can provide a confidential assessment of information provided by the carrier.

19

Appendix

20

Key terms and phrases used in this toolkit

Adapted from the Human Rights Campaign Foundations Transgender-Inclusive Health Care Coverage and the Corporate Equality Index which can be found at www.hrc.org/transbenefits Gender: Refers to the roles, behaviors, activities, and attributes that a given society considers appropriate for women and men. A social term rather than a biological one. Sex: The classification of people as male or female. At birth, infants are typically assigned a sex based on the appearance of their genitals, although clinically speaking, sex is a combination of bodily characteristics including chromosomes, hormones, internal reproductive organs and genitalia. Sex is separate from gender. Gender identity: Ones personal sense of their gender. For transgender people, their birth-assigned sex and their own sense of gender identity may not match and this disconnect can be profound. Few people ever question the distinction between their biological sex and their inner sense of their own gender (their gender identity) because for most, these two traits are completely congruent. However, for transgender individuals, this is not the case. Transgender: An umbrella term for individuals whose internal sense of self is not in line with the sex that was assigned to them at birth. You may sometimes hear individuals referred to as a trans man (usually referring to female-to-male transgender people) or a trans woman (usually referring to male-to-female transgender people). The terms signify current gender status as a man or woman while still affirming their gender history. Transition: Usually used to refer to the process of affirming a transgender persons gender identity. This may include a medical process in which changing social gender presentation (through clothing, gender pronouns, name, and more) is a key component. Transition-related care: Describes health care that transgender people may access during transition. This can include counseling, hormones (like testosterone or estrogen), hormone blockers, and/or genital and non-genital surgeries. This care is pejoratively referred to as a sex change, which is neither preferred nor accurate. Gender Dysphoria: Recently changed from Gender Identity Disorder in the Diagnostic and Statistical Manual V (DSM-V) (due for publication May 2013), Gender Dysphoria is the psychological diagnosis associated with transgender identities. Due to what some transgender people believe is its pathologizing nature, this diagnosis is hotly contested in transgender communities. However, it is the current mechanism for providing or denying access to health care for transgender individuals, and is tied to well-established and widely-accepted standards of care for transgender individuals. Individuals often become aware of the conflict between their gender identity and biological sex by the time they are about four to six years old; this is when Gender Dysphoria is sometimes first reported. As defined by the DSM-V, individuals with Gender Dysphoia are those with a strong desire to be of the other gender (or some alternative gender different from ones assigned gender) and to be treated as the other gender.

21

The intent of employer-provided health care coverage is to promote a productive and healthy workforce. For this population of people with Gender Dysphoria, the consequences of continuing to live in extreme discomfort may be severe. People who are denied transition-related care may suffer intense psychological distress that often takes the forms of depression, suicidality, and stress-related physical illnesses. As affirmed by numerous medical and allied health associations including the American Medical Association, American Psychological Association, and the National Association of Social Workers, the goal of care for Gender Dysphoria (psychotherapeutic, endocrine, and surgical therapies) is lasting personal comfort and congruency with the embodied self, resolution of clinically significant distress, and to maximize overall psychological and physical well-being. Inclusive coverage options for transition-related care help to achieve the goal of promoting health and wellness across the spectrum of workforce diversity.

22

Health care plans 101

Health Maintenance Organization (HMO)
An HMO is an organization that provides or arranges managed care for health insurance. When you sign up for an HMO, you must choose an individual primary care provider (PCP) within an HMO network. HMOs cover care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMOs guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care providers contracted status, but wont cover care out of its network.

Preferred Provider Organizations (PPO)

A preferred provider organization is a managed care organization of medical doctors, hospitals, and other health care providers who have contracted with an insurer or a third-party administrator to provide health care at reduced rates to the insurers or administrators clients. One difference between PPOs and HMOs is that PPOs will cover some coverage from providers outside of the PPO network.

Point of Service (POS)

With this plan, you can choose whether to use the HMO or PPO option when you see a provider. POS (Point of Service) plans have similar rules to HMOs, though they tend to be more flexible in offering referrals outside of the network and providing some coverage for self-referrals. If employees visit their primary care provider and receive referrals to specialists when necessary, their costs and coverage are likely to be similar to an HMO. However, if they refer themselves to a specialist or doctor outside of the plans network, they may need to pay a deductible and coinsurance (a portion of the medical fees).

Exclusive Provider Organization (EPO)

An Exclusive Provider Organization (EPO) involves a network of medical care providers, which provide health care to the subscribers of the health insurer. The subscribers are required to choose a primary care physician from within the network.

Fee for service (Indemnity) (FFS)

Fee for service health insurance plans are the least restrictive and offer a wider range of choices of medical specialists and facilities. If you have a policy that is fee for service based you can choose the health care provider and facility you want. Before the insurance provider gives money for these services, the insured has to pay a preset deductible amount. Even when insured you will have to pay 20% out of your pocket for every service. Stipulated in the insurance contract is the maximum amount required to be paid by the insured.

Health Savings Account (HSA)

Designed to help individuals save for future qualified medical and retiree health expenses on a tax-free basis.

23

Ending gender identity discrimination in health care

We all know someone who has been denied medically necessary care by an insurance company working to protect its bottom line. Its unfair, painful, and downright dangerous when it happens. And it happens all too often. Many people in Oregon continue to experience discrimination by insurance companies and health care service plans on the basis of gender, particularly members of Oregons transgender community. Many transgender Oregonians are denied the ability to purchase health insurance or are denied coverage for basic, medically necessary care solely because they are transgender. Without health insurance, many transgender people have no access to health care and have nowhere to turn if they develop health problems. Transgender specific exclusions are wrong, discriminatory and must come to an end as we strive to create a system of healthcare where every Oregonian can access the care they need to live healthy and productive lives.

Just the facts

Discrimination in health care

Medically necessary care

Oregon law says you cant fire someone simply because they are transgender. Oregon law says insurance companies must cover mental health conditions on par with coverage for physical health conditions. The American Medical Association, in addition to many other health care organizations, has defined transgender health care as being medically necessary. Despite all this, insurance companies continue to discriminate in the mental and physical care they will provide to transgender people. This is why Basic Rights Education Fund and transgender community leaders are working together to end gender identity discrimination in healthcare and health insurance coverage. This effort is about allowing every Oregonian access to the care they need to live healthy and productive lives. Ending insurance companies discriminatory policies that deny people access to medically necessary care and educating providers is the right thing to do.

Insurance industry exclusions

Many insurance companies refuse to provide insurance to transgender people based on their transgender status or by specifically excluding transgender-related services. Nearly all insurance plans categorically exclude coverage for transgender-related medical treatment, even when that treatment (such as mental health care or hormone replacement therapy) is covered for non-transgender people. Additionally, transgender people are often discriminated against based on their gender. For example, one transgender person who identified as male with his insurance company and later developed uterine cancer was denied payment for his cancer treatment, because his insurance plan did not treat uteruses in men. This type of discrimination is all too common and can lead to serious even life-threatening conditions. In January 2013, Oregons Insurance Division of the Department of Consumer and Business Services (DCBS) announced that insurance companies doing business in Oregon must end discriminatory exclusions of medically-

24

necessary health care for transgender Oregonians. The bulletin specifically states that: health insurers may not categorically exclude transgender patients from coverage health insurers must provide coverage and cannot deny coverage of treatments for transgender policy holders if the same treatments are covered for other policy holders health insurers may not deny treatment on the basis of a policy holders actual or perceived gender. That means that all policy holders can rely on annual exams, cancer screenings, and gender-specific health care, regardless of their gender on file. the statewide mandate for coverage of mental health services must apply to transgender patients.

Gender identity discrimination

Due to pre-existing conditions or a prior gender identity related diagnosis, many transgender people find it hard to purchase insurance or to access coverage for basic, medically necessary care they needoften for services or treatments these insurance companies cover for non-transgender Oregonians. For example, thousands of women experiencing menopause are prescribed estrogen and other hormones; but transgender women are often denied similar prescription hormones.

Solution: prohibit exclusions

The solution to this problem is to put health care back in the hands of patients and doctorsnot the insurance companies. Its time to end insurance companies discriminatory practices and remove the barriers to medically necessary care for transgender Oregonians.

Cost of coveragenegligible

In 2001, the City and County of San Francisco became the first US municipality to provide this medically necessary care by removing transgender access exclusions in its health plans. The city and county originally thought a small surcharge of $1.70 per member/per month would be necessary to cover the health care. Actual costs turned out to be far, far lower than anticipated however, and in 2006 the city dropped the surcharge altogether because the cost was de minimis or so small as to be negligible.

Good for Oregon workforce and economy

Currently, 25% of Fortune 100 Companies and many Oregon businesseslarge and smalloffer inclusive health care to all workers, including healthcare for transgender workers. These businesses believe that providing all workers with the medically-necessary care they need to be healthy and productive is not just good for workers and their families, and not just the right thing to dothey know it is good for business. Dozens of Oregon businesses offer transgender-related coverage to their employees including Alcatel-Lucent, American Express, Ameriprise Financial, Chrysler Motors, Kimpton Hotel & Restaurant Group, Kraft Foods, Microsoft, New Seasons Market, Oregon Health and Science University (OHSU), and the Port of Portland.

Decisions about health care should be made between doctors and patients, not by insurance companies. Ending this unfair and unnecessary exclusion is the right thing to do. All Oregonians should be able to access the care they need.
For more information, contact Basic Rights Oregon at 503-222-6151 or online at www.basicrights.org.

25

Transition-related care: medically necessary

Adapted from the Human Rights Campaign Foundations Transgender-Inclusive Health Care Coverage and the Corporate Equality Index www.hrc.org/transbenefits In recent years, as discriminatory health care practices against transgender individuals have gained visibility, an increasingly vocal consensus has emerged from the medical and allied health professionals to affirm the need for adequate healthcare and healthcare coverage for transgender individuals.

The World Professional Association for Transgender Health

In June 2008, World Professional Association for Transgender Health (WPATH) issued a Clarification Statement urging health insurance carriers and healthcare providers in the U.S. to eliminate transgender or trans-sex exclusions and to provide coverage for transgender patients and the medically prescribed sex reassignment services necessary for their treatment and well-being.

The American Medical Association

A growing number of allied health associations have similarly issued strong policy statements calling for the elimination of insurance exclusions. In 2008, the American Medical Association issued Resolution 122 calling for Removing Financial Barriers to Care for Transgender Patients which has been incorporated as part of the AMA Policy Regarding Sexual Orientation. In the background argument, the resolution underscored that, An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy, and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID, and that health experts in GID, including WPATH have recognized that these treatments can provide safe and effective treatment for a serious health condition. The AMA also underscored the negative health outcomes caused by delays in treatment. Noting that much transition-related care involves services usually covered for other diagnoses (e.g., mastectomy or breast reconstruction, hysterectomy, and other reconstructive surgeries), the AMA called coverage denials based on a GID diagnosis discrimination. RESOLVED, That our American Medical Association support public and private health insurance coverage for treatment of Gender Identity Disorder as recommended by the patients physician. (American Medical Association House of Delegates Resolution 122, 2008)

The National Association of Social Workers

The National Association of Social Workers (NASW) revised its transgender policy statement in August 2008: NASW supports the rights of all individuals to receive health insurance and other health coverage without discrimination on the basis of gender identity, and specifically without exclusion of services related to transgender or transsexual transition (or sex change), in order to receive medical and mental health services [...] which may include hormone replacement therapy, surgical interventions, prosthetic devices, and other medical procedures. (NASW Policy Statement on Transgender and Gender Identity Issues, in Social Work Speaks, 2009)

26

The American Psychological Association

The American Psychological Association (APA) issued a similarly strong policy statement, noting for example that transgender people may be denied appropriate gender transition related medical and mental health care despite evidence that appropriately evaluated individuals benefit from gender transition treatments. APA recognizes the efficacy, benefit and medical necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments. (APA Policy Statement, 2008)

27

American Medical Association: Resolution on transgender health care

Resolution: 114 April 14, 2008 Whereas, Gender Identity Disorder (GID) is a serious medical condition recognized as such in both the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases; and Whereas, GID, if left untreated, can result in clinically significant psychological distress, dysfunction, debilitating depression, and, for some patients without access to appropriate medical care and treatment, suicidality and death; and Whereas, The medical literature has established the effectiveness and medical necessity of mental health care, hormone therapy, and sex reassignment surgery in the treatment of patients diagnosed with GID; and Whereas, Many health insurance plans categorically exclude coverage of mental health, medical, and surgical treatments for GID, even though many of these same treatments, such as psychotherapy, hormone therapy, breast augmentation and removal, hysterectomy, oophorectomy, orchiectomy, and salpingectomy, are covered for other medical conditions; and Whereas, The denial of otherwise covered benefits for patients diagnosed with GID represents discrimination based solely on a patients gender identity; and Whereas, Our AMA opposes discrimination (AMA Policies H-65.983, H-65.992) and the denial of health insurance (H-180.980) on the basis of gender identity; and Whereas, Our AMA opposes limitations placed on patient care by third-party payers when such care is based upon sound scientific evidence and sound medical opinion (H-120.988); therefore be it RESOLVED, That our American Medical Association support public and private health insurance coverage for treatment of Gender Identity Disorder in adolescents and adults (New HOD Policy); and be it further RESOLVED, That our AMA oppose categorical exclusions of coverage for treatment of Gender Identity Disorder in adolescents and adults when prescribed by a physician. (New HOD Policy) Fiscal Note: Staff cost estimated at less than $500 to implement. RELEVANT AMA POLICY H-65.983 Nondiscrimination Policy The AMA affirms that it has not been its policy now or in the past to discriminate with regard to sexual orientation or gender identity. (Res. 1, A-93; Reaffirmed: CCB Rep. 6, A-03; Modified: BOT Rep. 11, A-07)

28

H-65.992 Continued Support of Human Rights and Freedom Our AMA continues (1) to support the dignity of the individual, human rights and the sanctity of human life, and (2) to oppose any discrimination based on an individuals sex, sexual orientation, gender identity, race, religion, disability, ethnic origin, national origin or age and any other such reprehensible policies. (Sub. Res. 107, A-85; Modified by CLRPD Rep. 2, I-95; Reaffirmation A-00; Reaffirmation A-05; Modified: BOT Rep. 11, A-07) H-180.980 Sexual Orientation and/or Gender Identity as Health Insurance Criteria The AMA opposes the denial of health insurance on the basis of sexual orientation or gender identity. (Res. 178, A-88; Reaffirmed: Sub. Res. 101, I-97; Reaffirmed: CMS Rep. 9, A-07; Modified: BOT Rep. 11, A-07) H-120.988 Patient Access to Treatments Prescribed by Their Physicians The AMA confirms its strong support for the autonomous clinical decision-making authority of a physician and that a physician may lawfully use an FDA approved drug product or medical device for an unlabeled indication when such use is based upon sound scientific evidence and sound medical opinion; and affirms the position that, when the prescription of a drug or use of a device represents safe and effective therapy, third party payers, including Medicare, should consider the intervention as reasonable and necessary medical care, irrespective of labeling, should fulfill their obligation to their beneficiaries by covering such therapy, and be required to cover appropriate off-label uses of drugs on their formulary (Res. 30, A-88; Reaffirmed: BOT Rep. 53, A-94; Reaffirmed and Modified by CSA Rep. 3, A-97; Reaffirmed and Modified by Res. 528, A-99; Reaffirmed: CMS Rep. 8, A-02; Reaffirmed: CMS Rep. 6, A-03; Modified: Res. 517, A-04; Reaffirmation I-07; Reaffirmed: Res. 819, I-07)

29

American Psychological Association:

Resolution on transgender non-discrimination
Whereas transgender and gender variant people frequently experience prejudice and discrimination and psychologists can, through their professional actions, address these problems at both an individual and a societal level; Whereas the American Psychological Association opposes prejudice and discrimination based on demographic characteristics including gender identity, as reflected in policies including the Hate Crimes Resolution (Paige, 2005), the Resolution on Prejudice Stereotypes and Discrimination (Paige, 2007), APA Bylaws (Article III, Section 2), the Ethical Principles of Psychologists and Code of Conduct (APA 2002, 3.01 and Principle E); Whereas transgender and other gender variant people benefit from treatment with therapists with specialized knowledge of their issues (Lurie, 2005; Rachlin, 2002), and that the Ethical Principles of Psychologists and Code of Conduct state that when scientific or professional knowledge ...is essential for the effective implementation of their services or research, psychologists have or obtain the training....necessary to ensure the competence of their services... (APA 2002, 2.01b); Whereas discrimination and prejudice against people based on their actual or perceived gender identity or expression detrimentally affects psychological, physical, social, and economic well-being (Bockting et al., 2005; Coan et al., 2005; Clements-Nolle, 2006; Kenagy, 2005; Kenagy & Bostwick, 2005; Nemoto et al., 2005; Resolution on Prejudice Stereotypes and Discrimination, Paige, 2007; Riser et al., 2005; Rodriquez-Madera & ToroAlfonso, 2005; Sperber et al., 2005; Xavier et al., 2005); Whereas transgender people may be denied basic non-gender transition related health care (Bockting et al., 2005; Coan et al., 2005; Clements-Nolle, 2006; GLBT Health Access Project, 2000; Kenagy, 2005; Kenagy & Bostwick, 2005; Nemoto et al., 2005; Riser et al., 2005; Rodriquez-Madera & Toro-Alfonso, 2005; Sperber et al., 2005; Xavier et al., 2005); Whereas gender variant and transgender people may be denied appropriate gender transition related medical and mental health care despite evidence that appropriately evaluated individuals benefit from gender transition treatments (De Cuypere et al., 2005; Kuiper & Cohen-Kettenis, 1988; Lundstrom, et al., 1984; Newfield, et al., 2006; Pfafflin & Junge, 1998; Rehman et al., 1999; Ross & Need, 1989; Smith et al., 2005); Whereas gender variant and transgender people may be denied basic civil rights and protections (Minter, 2003; Spade, 2003) including: the right to civil marriage which confers a social status and important legal benefits, rights, and privileges (Paige, 2005); the right to obtain appropriate identity documents that are consistent with a post-transition identity; and the right to fair and safe and harassment-free institutional environments such as care facilities, treatment centers, shelters, housing, schools, prisons and juvenile justice programs; Whereas transgender and gender variant people experience a disproportionate rate of homelessness (Kammerer et al., 2001), unemployment (APA, 2007) and job discrimination (Herbst et al., 2007), disproportionately report income below the poverty line (APA, 2007) and experience other financial disadvantages (Lev, 2004);

30

Whereas transgender and gender variant people may be at increased risk in institutional environments and facilities for harassment, physical and sexual assault (Edney, 2004; Minter, 2003; Peterson et al., 1996; Witten & Eyler, 2007) and inadequate medical care including denial of gender transition treatments such as hormone therapy (Edney, 2004; Peterson et al., 1996; Bockting et al., 2005; Coan et al., 2005; Clements-Nolle, 2006; Kenagy, 2005; Kenagy & Bostwick, 2005; Nemoto et al., 2005; Newfield et al., 2006; Riser et al., 2005; RodriquezMadera &Toro-Alfonso, 2005; Sperber et al., 2005; Xavier et al., 2005); Whereas many gender variant and transgender children and youth face harassment and violence in school environments, foster care, residential treatment centers, homeless centers and juvenile justice programs (DAugelli, Grossman, & Starks, 2006; Gay Lesbian and Straight Education Network, 2003; Grossman, DAugelli, & Slater, 2006); Whereas psychologists are in a position to influence policies and practices in institutional settings, particularly regarding the implementation of the Standards of Care published by the World Professional Association of Transgender Health (WPATH, formerly known as the Harry Benjamin International Gender Dysphoria Association) which recommend the continuation of gender transition treatments and especially hormone therapy during incarceration (Meyer et al., 2001); Whereas psychological research has the potential to inform treatment, service provision, civil rights and approaches to promoting the well-being of transgender and gender variant people; Whereas APA has a history of successful collaboration with other organizations to meet the needs of particular populations, and organizations outside of APA have useful resources for addressing the needs of transgender and gender variant people; Therefore be it resolved that APA opposes all public and private discrimination on the basis of actual or perceived gender identity and expression and urges the repeal of discriminatory laws and policies; Therefore be it further resolved that APA supports the passage of laws and policies protecting the rights, legal benefits, and privileges of people of all gender identities and expressions; Therefore be it further resolved that APA supports full access to employment, housing, and education regardless of gender identity and expression; Therefore be it further resolved that APA calls upon psychologists in their professional roles to provide appropriate, nondiscriminatory treatment to transgender and gender variant individuals and encourages psychologists to take a leadership role in working against discrimination towards transgender and gender variant individuals; Therefore be it further resolved that APA encourages legal and social recognition of transgender individuals consistent with their gender identity and expression, including access to identity documents consistent with their gender identity and expression which do not involuntarily disclose their status as transgender for trans-

31

gender people who permanently socially transition to another gender role; Therefore be it further resolved that APA supports access to civil marriage and all its attendant benefits, rights, privileges and responsibilities, regardless of gender identity or expression; Therefore be it further resolved that APA supports efforts to provide fair and safe environments for gender variant and transgender people in institutional settings such as supportive living environments, long-term care facilities, nursing homes, treatment facilities, and shelters, as well as custodial settings such as prisons and jails; Therefore be it further resolved that APA supports efforts to provide safe and secure educational environments, at all levels of education, as well as foster care environments and juvenile justice programs, that promote an understanding and acceptance of self and in which all youths, including youth of all gender identities and expressions, may be free from discrimination, harassment, violence, and abuse; Therefore be it further resolved that APA supports the provision of adequate and necessary mental and medical health care treatment for transgender and gender variant individuals; Therefore be it further resolved that APA recognizes the efficacy, benefit and medical necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments; Therefore be it further resolved that APA supports access to appropriate treatment in institutional settings for people of all gender identities and expressions; including access to appropriate health care services including gender transition therapies; Therefore be it further resolved that APA supports the creation of educational resources for all psychologists in working with individuals who are gender variant and transgender; Therefore be it further resolved that APA supports the funding of basic and applied research concerning gender expression and gender identity; Therefore be it further resolved that APA supports the creation of scientific and educational resources that inform public discussion about gender identity and gender expression to promote public policy development, and societal and familial attitudes and behaviors that affirm the dignity and rights of all individuals regardless of gender identity or gender expression; Therefore be it further resolved that APA supports cooperation with other organizations in efforts to accomplish these ends.

Anton, Barry S. (2009). Proceedings of the American Psychological Association for the legislative year 2008: Minutes of the annual meeting of the Council of Representatives, February 22-24, 2008, Washington, DC, and August 13 and 17, 2008, Boston, MA, and minutes of the February, June, August, and December 2008 meetings of the Board of Directors. American Psychologist 64, 372-453. doi:10.1037/a0015932

32

Medical necessity and standards of care

A key feature of every inclusive health plan is, of course, the removal of explicit exclusions of transition-related health care. But beyond removing exclusions, what do we need to cover in order to be truly inclusive? All transition-related health care services that are medically necessary as determined by a patient in consultation with their physician should be covered, including, but not limited to: consultation, follow up, and repair (if necessary). All deductibles, co-pays, benefit maximums or other restrictions should be commensurate with those offered to non-transgender individuals. Medical leave for transition-related care should be applied in the same manner as leave for any other medical treatment. Medically necessary transition-related health care services may include, but are not limited to:

Genital Surgical Procedures

Clitoroplasty Labiaplasty Vaginoplasty Orchiectomy Urethroplasty Phalloplasty Glansplasty Total abdominal Hysterectomy Vaginectomy Metoidioplasty Scrotoplasty Testicular Prosthesis

Non-Genital Surgical Procedures

Chest Reconstruction/Mastectomy & Reconstructive Procedures Facial Feminization Surgery (FFS) Augmentation Mammoplasty Voice Therapy Tracheal Shaving Voice Modulation Surgery Liposuction/ Lipoplasty Blepharoplastyz Therapy and Counseling, Mental health counseling related to gender identity. Hormone Replacement Therapy, including, but not limited to Testosterone, Estrogen, Progesteone, Anti-androgens, Gonadotropin releasing hormones (GnRH analogs), Depo-Lupron and other puberty blocking or precocious puberty related hormonal therapy. Includes injection and topical applications. Travel and Lodging related to surgery Gamete preservation in anticipation of future infertility Assisted Reproductive Technology (ART)

33

Insurance Policies that Include Transgender-Related Healthcare

While many insurance plans have outdated exclusions for transgender-related healthcare, there are several policies available that do not contain these exclusions. The Human Rights Campaign has developed a list of some of these insurance carriers and you can access links to specific plan language at http://www.hrc.org/resources/entry/finding-insurance-for-transgender-relatedhealthcare: Aetna Amerihealth Anthem BCBS BCBS Massachusetts BCBS Minnesota BCBS Michigan (Blue Care Network HMO) Cigna EmblemHealth HealthNet HealthPartners Independence Blue Cross Medica

Standards of Care for Transgender Health

The most widely recognized standard of practice is published by the World Professional Association for Transgender Health (WPATH), formerly the Harry Benjamin International Gender Dysphoria Association (HBIGDA). The WPATH Standards of Care (SOC) have been recognized by several national medical and mental health organizations and their memberships: the American Medical Association, the American Psychological Association and the National Association of Social Workers. In addition to these organizations, the standards have been widely accepted in numerous psychiatric textbooks. Referencing the WPATH Standards of Care at the outset of advocacy for inclusive coverage serves as powerful validation, clearly conveying both the existence of medical consensus that transition-related care is medically necessary and the existence of accepted protocols. The WPATH SOC articulates the assessment process to be used by providers in guiding treatment decisions to enable provider and patient to find the medical pathway that will be most successful for that individual. In the absence of a standard protocol adhering to WPATH (where exclusions are removed but treatment is not affirmed), eligibility and utilization management decisions made by insurance company representatives are vulnerable to the missteps born of misconceptions.

34

The most recent version of the WPATH SOC was released in fall 2011. The major differences between the WPATH SOC Version 6 and Version 7 can be summarized as follows: New title: Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (Version 6 was entitled Standards of Care for Gender Identity Disorders). SOC Version 7 describes what professionals need to do rather than what the client needs to do to qualify for treatment. Flexibility recognition of client/patients unique circumstances, and appropriate uses of informed consent. More detailed clinical guidelines, with scholarly references to provide context and evidence base. More than simply providing assessment guidelines for hormones and surgery, the SOC now promotes overall health and well-being. SOC Version 7 contains a clear statement that gender nonconformity is not pathological and includes medical necessity principles.

The World Professional Association for Transgender Health can be accessed at: www.wpath.org

35

Transition-related care: Affordable

No jurisdiction, employer, or insurance company which covers trans health care has found the cost to be prohibitive. In 2011, the City of Portland determined that the cost increase was only .08% of its health care insurance budget.

Lifetime Max Coverage $15,000 $50,000

Anticipated cost, 2011-2012 $27,026 $32,302

Anticipated premium impact, 2011-2012 0.07% 0.08%

Multnomah County has seen low utilization since 2011. In January 2010, Multnomah County extended our healthcare benefit coverage to include transgender surgical care. Since implementation of this coverage, the per member per month cost increase has been less than a dollar per person. Multnomah County Commissioner Jeff Cogen The City and County of San Francisco have provided comprehensive coverage for years with research showing no discernible cost. Initially, concerns were raised that cost would be high, that utilization would increase, or that providing inclusive care would be somehow unmanageable for the city. Over time, these concerns were disproven, as cost and utilization were both much lower than anticipated so low, in fact, that the cost of care was declared de minimis so small as to be negligible. 2001: The City and County removed transgender exclusions from their plan. They anticipated this would carry a cost so they implemented a per employee per month (PEPM) surcharge at $1.70. Between 2001 and 2005, the city generated several million dollars in additional premium payments, but paid out just $183,000 for eleven claims on surgery. 2005: The PEPM surcharge dropped to $1.16 for those on the Citys HMO plan, and just 50 cents for the Citys self-insured health plan. 2007: The cost of the benefit was determined to negligible and the surcharge was completely dropped. 2012: After 11 years, costs have continued to be de minimis.

36

IRS ruling on transition-related health care

ODonnabhain v. Commissioner, 134 T.C. No. 4 (2010)

Issue:
This case was brought to the United States Tax Court in 2010. The issue for the court was whether a taxpayer who has been diagnosed with Gender Identity Disorder can deduct sex reassignment surgery and hormone replacement therapy costs as necessary medical expenses under the tax code. The IRS argued that sex reassignment surgery is cosmetic and not medically necessary. The U.S. Tax Court ruled against the IRS and said that the plaintiff should be allowed to deduct the costs of her treatment for gender-identity disorder, including sex-reassignment surgery and hormone treatments. The US Tax Court found the IRS position that treatment should be viewed as cosmetic to be at best a superficial characterization of the circumstances that is thoroughly rebutted by the medical evidence.

Holding:
The Tax Court ruled that hormone therapy and sex-reassignment surgery are valid treatments for Gender Identity Disorder and the costs of these procedures are deductible under the Internal Revenue Code.

Appeal:
The deadline for the government to appeal the decision was February 7th, 2011, and the government chose not to challenge the decision, making it binding on future Internal Revenue Service practices.

37

38

39

MEMORANDUM DATE: April 18, 2012 SUBJECT: City of Portland Cost Analysis for Transgender Healthcare Benefits The City of Portland implemented transgender healthcare surgical benefits in July of 2011. Benefit design changes are first discussed within the Citys Labor Management Benefits Committee. The Committee first discussed the issue in 2009. After a number of conversations and votes within the Committee, the transgender coverage issue was ultimately decided before City Council. To determine the cost of the benefit the Citys process was as follows:

Determine what services supporting transgender healthcare were already covered under the health plan. Review other jurisdictions/organizations providing the coverage to understand plan coverage differences and costing strategies. Review sample plan benefit designs from other jurisdictions to understand coverage/limitations/exclusion languages. Review national and local prevalence data/assumptions. The Citys consulting office used the GID Reform Advocates information and Multnomah Countys costing strategy to gain some information on prevalence. The Citys consulting office initially used the national prevalence data assumptions to calculate rates for the 2010 plan year. This national prevalence data was lower. That rate was established at $1.51 per employee per month. This benefit was not approved for the 2010-11 plan year. The following year the rate was further decreased to $0.76 per employee per month because the prevalence within the local market was low. (e.g. Multnomah County experience was low). The benefit was approved through Council and became effective July 1, 2011. Monitor experience moving forward to adjust if needed.

40

41

42

43

44

STATE OF CALIFORNIA DEPARTMENT OF INSURANCE ECONOMIC IMPACT ASSESSMENT GENDER NONDISCRIMINATION IN HEALTH INSURANCE
In 2012, the California Department of Insurance released an economic impact assessment comparing the costs and benefits of inclusive health insurance for transgender people. The experts at the Department concluded that there was an immaterial impact on premium costs and that the benefits of eliminating discrimination far exceed the insignificant costs. From page 9 of the assessment: Department staff reviewed data from five employers that have internal policies prohibiting discrimination in health care coverage and reviewed their related cost studies. For reasons discussed in the following section, the Department has concluded the impact on costs, due to the adoption of the proposed regulation, would be immaterial ...The Department has determined that the benefits of eliminating discrimination far exceed the insignificant costs associated with implementation of the proposed regulation. Based on this assessment, the Department has determined that there are no significant adverse impacts of the regulation to the health and welfare of California residents, nor will it impact overall worker safety, and the states environment. Further, the Departments evidence suggests that benefits will accrue to insurance carriers and employers as costs decline for the treatment of complications arising from denial of coverage for treatments. The evidence suggests that there may be potential cost savings resulting from the adoption of the proposed regulation in the medium to long term, such as lower costs associated with the high cost of suicide and attempts at suicide, overall improvements in mental health and lower rates of substance abuse For the full text, please visit http://transgenderlawcenter.org/archives/5616.

45

Transition-related care: Good for workplaces

From the Human Rights Campaign Corporate Equality index, Including Surgical Procedures http://www.hrc.org/cei2011/index.html Businesses based or operating in Oregon offering transgender-inclusive care 3M Co. Aetna Inc. Alcatel-Lucent American Express Co. Ameriprise Financial Inc. AT&T Inc. Avaya Inc. Bank of America Corp. Campbell Soup Co. Chrysler Group LLC Cisco Systems Inc. Citigroup Inc. The Coca-Cola Co. Exelon Corp. Federal Home Loan Mortgage Corp. (Freddie Mac) Ford Motor Co. Genentech Inc. General Motors Co. The Goldman Sachs Group Inc. Google Inc. Intel Corp. International Business Machines Corp. (IBM) Johnson & Johnson JPMorgan Chase & Co. Kimpton Hotel and Restaurant Group KPMG LLP Kraft Foods Inc. The McGraw-Hill Companies Inc. Microsoft Corp. Morgan Stanley New Seasons Nike Inc. Oracle Corp. PepsiCo Inc. PG&E Corp. PricewaterhouseCoopers LLP Sears Holdings Corp. State Farm Group UAL Corp. (United Airlines) The Walt Disney Co. Wells Fargo & Co. Yahoo! Inc.

46

US businesses with transgender-inclusive health plans

Adapted from the Human Rights Campaign Foundations Transgender-Inclusive Health Care Coverage and the Corporate Equality Index www.hrc.org/transbenefits 3M Co. A.T. Kearney Inc. AAA Northern California, Nevada & Utah Insurance Exchange Abercrombie & Fitch Co. Accenture Ltd. Aetna Inc. Akin, Gump, Strauss, Hauer & Feld LLP Alcatel-Lucent Alcoa Inc. Alston & Bird LLP American Express Co. Ameriprise Financial Inc. AMR Corp. (American Airlines) Aon Corp. Apple Inc. AT&T Inc. Automatic Data Processing Inc. Avaya Inc. Avon Products Inc. Bain & Co. Inc. Baker & McKenzie LLP Bank of America Corp. Bank of New York Mellon Corp., The (BNY Mellon) Barclays Capital Barnes & Noble Inc. Best Buy Co. Inc. Bingham McCutchen LLP BlackRock Blue Cross Blue Shield of Florida Inc. Blue Cross Blue Shield of Minnesota BMO Bankcorp Inc. Booz Allen Hamilton Inc. Boston Consulting Group Bristol-Myers Squibb Co. Broadridge Financial Solutions Inc. Brown Rudnick LLP Brown-Forman Corp. Bryan Cave LLP Caesars Entertainment Corp. Campbell Soup Co. Capital One Financial Corp. Cardinal Health Inc. CareFusion Corp. Cargill Inc. Carlton Fields PA Chapman and Cutler LLP Charles Schwab Corp., The Chevron Corp. Choate, Hall & Stewart LLP Choice Hotels International Inc. Chrysler LLC Chubb Corp. Cisco Systems Inc. Citigroup Inc. Clifford Chance US LLP Clorox Co. Coca-Cola Co., The Comerica Inc. Corning Inc. Covington & Burling LLP Credit Suisse USA Inc. Crowell & Moring LLP Cummins Inc. Davis Wright Tremaine LLP Debevoise & Plimpton LLP Delhaize America Inc. Dell Inc. Deloitte LLP Deutsche Bank Dewey & LeBoeuf LLP Diageo North America DLA Piper Dorsey & Whitney LLP Dow Chemical Co., The Dykema Gossett PLLC E. I. du Pont de Nemours and Co. (DuPont) Eastman Kodak Co. eBay Inc. Edwards Angell Palmer & Dodge LLP Eli Lilly & Co. EMC Corp. Ernst & Young LLP Exelon Corp. Faegre & Benson LLP Federal Home Loan Mortgage Corp. (Freddie Mac) Fenwick & West LLP Ford Motor Co. Fried, Frank, Harris, Shriver & Jacobson LLP Gap Inc. Genentech Inc. General Mills Inc. General Motors Co. Gibson, Dunn & Crutcher LLP GlaxoSmithKline plc Goldman Sachs Group Inc., The Google Inc. Group Health Cooperative Group Health Permanente Herman Miller Inc. Hewlett-Packard Co. Hinshaw & Culbertson LLP Hogan Lovells US LLP

47

Hyatt Hotels Corp. ING North America Insurance Corp. Intel Corp. International Business Machines Corp. (IBM) Intuit Inc. Jenner & Block LLP Johnson & Johnson JPMorgan Chase & Co. K&L Gates LLP Kellogg Co. Kimpton Hotel & Restaurant Group Inc. Kirkland & Ellis LLP KPMG LLP Kraft Foods Inc. Levi Strauss & Co. Limited Brands Inc. Littler Mendelson PC Lockheed Martin Corp. Marsh & McLennan Companies Inc. McDermott Will & Emery LLP McKinsey & Co. Inc. Medtronic Inc. MetLife Inc. Microsoft Corp. MillerCoors LLC Mitchell Gold + Bob Williams Morgan Lewis & Bockius LLP Morgan Stanley Morrison & Foerster LLP Nationwide Navigant Consulting Inc. Nike Inc. Nixon Peabody LLP Nordstrom Inc. Northern Trust Corp. Office Depot Inc. Oracle Corp. Orbitz Worldwide Inc. Owens Corning Patterson Belknap Webb & Tyler LLP

Paul Hastings LLP Paul, Weiss, Rifkind, Wharton & Garrison LLP Pearson Inc. PepsiCo Inc. Perkins Coie LLP Pfizer Inc. PG&E Corp. Pillsbury Winthrop Shaw Pittman LLP PricewaterhouseCoopers LLP Prudential Financial Inc. Raytheon Co. Replacements Ltd. Robins, Kaplan, Miller & Ciresi LLP Rockwell Automation Inc. Ropes & Gray LLP Schiff Hardin LLP Sears Holdings Corp. Sedgwick, Detert, Moran & Arnold LLP Sempra Energy Seyfarth Shaw LLP Shearman & Sterling LLP Sheppard, Mullin, Richter & Hampton LLP Shook, Hardy & Bacon LLP Sidley Austin LLP Simpson, Thacher & Bartlett LLP Sodexo Inc. Southern California Edison Co. Sprint Nextel Corp. Squire, Sanders & Dempsey LLP Staples Inc. Starwood Hotels & Resorts Worldwide State Farm Group Sun Life Financial Inc. (U.S.) Supervalu Inc. Sutherland Asbill & Brennan LLP

Symantec Corp. TD Bank, N.A. Teachers Insurance and Annuity Association - College Retirement Equities Fund Tech Data Corp. Thompson Coburn LLP Thomson Reuters Tiffany & Co. Time Warner Inc. TJX Companies Inc., The Toyota Financial Services Corp. Toyota Motor Sales USA Inc. Troutman Sanders LLP U.S. Bancorp UBS AG Unilever United Continental Holdings Inc. United Technologies Corp. UnitedHealth Group Inc. Volkswagen Group of America Inc. Wachtell, Lipton, Rosen & Katz LLP Walt Disney Co., The Wells Fargo & Co. Whirlpool Corp. White & Case LLP Wilmer Cutler Pickering Hale & Dorr LLP Winston & Strawn LLP Xerox Corp. Yahoo! Inc.

48

Colleges and universities with transgender-inclusive health insurance plans

From the Human Rights Campaigns Transgender-Inclusive Benefits: Colleges & Universities www.hrc.org/transbenefits

Employee Health Plans

A partial list of colleges and universities with employee plans that provide minimum or better transgenderinclusive coverage including at least some transition-related surgeries: American University City University of New York (CUNY) Harvard University University of California Berkeley University of California Davis University of California Irvine University of California Los Angeles University of California Merced University of California Riverside University of California San Diego University of California San Francisco University of California Santa Barbara University of California Santa Cruz University of Michigan University of Pennsylvania Yale University

Student Health Plans

A partial list of colleges and universities with student health plans that provide minimum or better transgender-inclusive coverage including at least some transition-related surgeries.
Brown University California Institute of Technology Carnegie Mellon University Case Western University Colorado State University Cornell University Duke University Emerson College Emory University Harvard University Massachusetts Institute of Technology (MIT) National College of Natural Medicine (NCNM) New York University Northwestern University Portland State University Princeton Stanford University Stony Brook University Tufts University The University at Buffalo (SUNY Buffalo) University of California campuses listed above University of ColoradoBoulder University of Connecticut University of Michigan University of Minnesota University of Missouri University of Pennsylvania University of Vermont University of Washington Washington University in St. Louis Yale University

For regularly updated lists, visit: http://www.transgenderlaw.org/college/#health

49

Oregons Insurance Division Bulletin Banning Discrimination

In December 2012, the Oregon Department of Business and Consumer Services (DCBS) released a bulletin announcing that in order to comply with current statutes prohibiting gender discrimination, many health insurance plans sold in Oregon can no longer deny care to transgender policy holders which is provided to nontransgender (or cisgender) policy holders. DCBS oversees health insurance regulations in the state of Oregon. Because insurance companies must comply with DCBS regulations in order to sell insurance in the state, a bulletin from DCBS carries the force of law in Oregon. If your insurance is provided by your employer, please note that many larger businesses are based out of state and are governed by federal laws, like ERISA (the Employee Retirement Income Security Act), that preempt state level nondiscrimination protections. These businesses likely buy their insurance in another state and will be unaffected by this bulletin. Businesses that are self-insured may also be exempt from this bulletin. The bulletin specifically states that: Health insurers must provide coverage and cannot deny coverage of treatments for transgender policy holders if the same treatments are covered for other policy holders. If an insurer covers breast reduction surgery to lessen back pain, the insurer could not deny breast reduction surgery for gender transition if the provider deemed the treatment medically necessary. If hormone therapy is covered for other policyholders, it cannot be denied for gender transition if determined to be medically necessary. On the other hand, an insurer could exclude all coverage of breast implants or penile implants. In short, Oregon law requires equality in treatment. Health insurers may not have riders that categorically exclude all transgender patients. The statewide mandate for coverage of mental health services must apply to transgender patients. The designation of male or female may not be relevant to treatment (ie, a person cannot be denied an ovarian cancer screening on the basis that they identify as male). If you believe an insurer has unfairly denied a claim you must file an appeal through the insurance provider, after which an individual may appeal to an impartial medical panel for an external review. You may receive help with your complaint from an insurance consumer advocate by calling 1-888-877-4894 or visiting www. cbs.state.or.us/ins/consumer/tomake.html. To read the bulletin in its entirety, visit: http://bit.ly/DCBSbulletin. As of April 2013, state insurance divisions in California, Colorado, Vermont, and Washington, D.C. have realeased similar regulations.

50

Filing Complaints with Oregons Insurance Division

Why file a complaint? Filing a complaint is an important way to ensure that your individual needs are being addressed, and to notify the Insurance Division of larger problems facing insured people in the state. The Insurance Divisions complaints process From the Insurance Divisions Web site: Advocates educate consumers about their rights under the law, operate a hotline for consumers with questions or complaints about insurer or agent (producer) practices, and resolve issues before they lead to further consumer harm. Advocates do not act as an attorney for a person. Most consumers are helped through our informal efforts to resolve matters between consumers and insurers or agents. The main purpose of our consumer complaint process is to identify and eliminate the most serious threats to Oregon consumers. The consumer calls we receive are critical to protecting all insurance-buying consumers. Advocates refer potential violations of insurance law to our investigators for possible enforcement action. The Oregon Insurance Division can fine companies or agents that break the law and/or revoke their licenses. Based on consumer complaints, the advocates may detect areas of the law that need to be changed to give consumers additional protections. They may recommend creation of educational materials and outreach to consumer groups on a particular topic. Even though our advocates may not always be able to help you resolve your complaint, your calls assist other Oregonians by identifying issues of concern and potential problems facing the insurancebuying public. What does filing a complaint consist of? Complaint forms simply ask consumers to share basic information about their insurance (company name, policy number, claim number, etc), what their complaint is, and how they would like that complaint to be resolved. What happens when the Insurance Division receives a complaint? From the Insurance Divisions Web site: An advocate will: Provide written verification that your complaint was received Provide a copy of your complaint to the insurance company and/or agent Obtain a detailed response from the company and/or agent, including any supporting docu- mentation to support the position taken Analyze the response and supporting documentation Determine whether there has been a possible violation Advise you of our findings

51

Please be advised, we are not attorneys and we cannot act as a legal representative. As advocates, we make every effort to determine whether the company/agent complies with the insurance laws or terms of the insurance policy. Our intent is to find a resolution to your concerns. Results vary from providing clarifying information to getting a claim paid. Most complaints are resolved within 60 days but it depends on the type of complaint. Complaints are confidential. However, a copy will be sent to the insurance company/agent named in the complaint. Where to file complaints Complaints can be filed online at http://www.cbs.state.or.us/ins/consumer/tomake.html. If you have questions, call the consumer advocate hotline at 888-877-4894, 8am-5pm, Monday through Friday. For more information on the complaints process and the role of consumer advocates, visit http://www.cbs.state. or.us/ins/consumer/consumer-complaints/consumer-complaint-qa.html.

52

Sample personal story from a parent

My name is Debby. Before I had my daughter I had no idea what transgender was. I grew up in a small town, and I never knew any transgender peopleI had only heard of cross-dressers. I already had several children when I became pregnant with Edi. I went to see a counselor during the pregnancy, and she told me that this child picked me for a reason. I never understood that until now. I just knew that my child was my child, and I just wanted my child to be happy. I knew something was different about my child, and so did my husband. One day he told me, you know, Eddie might be gay, and that would be just fine with me. It was great, but it surprised meI didnt expect him to be so supportive. Then I saw an episode of 20/20 about transgender children, and something clicked. I saw it and I knew that was my child. I was relieved to know what was going on with my child, and that she was okay. After that, we had a lot of decisions to make. Edi decided to transition. She started wearing her favorite clothes, like her Hello Kitty rain boots, but we quickly found that our community wasnt as accepting as we would hope. Thats when we made the tough decision to leave our home town and move the family to Portland. And since that, things have gotten much better. Edis at a great school, and her teacher is supportive. Shes happy and shes healthy, and thats all I want for my child. We have had troubles with health insurance. We ran into some issues with insurance, who wouldnt even cover initial counseling for my child. I know this is just the beginningmany transgender people have a tough time getting health care. I want to make sure that she gets the health care she needs in the future. And I want to make sure that this doesnt happen to other children.

53

Sample personal story from an individual

My name is Ray Crider. I grew up in Southern Oregon, and moved to Portland about ten years ago. Four years ago, before I transitioned, I was known by a different name. I am luckier than most; my employer welcomed my transition with open arms. I wouldnt be the person I am today without the support I have gotten over the last four years from family, friends and my workplace. My workplace insurance policy, like most, excluded coverage of any and all transgender related health services. I worked with a group of employees and administrators to change our coverage. Now that Im able to access the care I need, a huge burden has been lifted. Before my insurance covered surgery, it would have been nearly impossible for me to afford it out of pocket. The daily struggle was incredibly difficult. Surgery coverage for me is preventive health care and heres why. Part of my daily routine is binding my chest, which is a common practice. My gender presentation is also a personal safety issueif my gender presentation doesnt make sense to the people I meet, I put myself at risk of emotional or even physical harm. Binding is painful and awkward but necessary. I cannot leave the house without it. However, binding is creating health problems for me, it restricts my breathing and its causing inflammation in the wall of my lungs. As a result I have ended up in the emergency room several times for shortness of breath and chest pain. Doctors tell me the only solution is to stop binding. It is unclear what the long-term health consequences of binding will be. Lack of access to health insurance coverage creates many problems, but also costs insurance companies. Transgender exclusions in insurance policies are a lose/lose proposition. It doesnt take very many trips to the emergency room to exceed the cost of the surgery they have excluded from their policies. Many of the procedures needed by trans people are routinely covered for non-transgender people, but the exclusions specifically target transgender people. Doctors deem many of these excluded services medically necessary for trans people and that should really be all it takes to access medical care. Gradually things are starting to change and I will continue this work until it is the exclusions are removed and every person, no matter their gender identity, will have access to equal healthcare.

54

Sample personal story from an individual

My name is Peter Dakota Molof and I am a student at Portland Community College. Im currently majoring in Womens & Gender Studies in order to pursue a career in public education and civic engagement. When I began my transition, I first spoke with my primary care physician. Then I ended up spending over four months talking to my insurance provider, at every turn encountered roadblocks preventing me from accessing medically necessary care. It felt frustrating to realize that so few people under my insurance knew what kind of care I needed, or how to get it to me. And it was even more frustrating to realize doctors are able to provide care that is deeply needed, but excluded by insurance companies. Because of these barriers to accessing medically necessary care, I experienced significant financial, personal, and emotional impacts. I had to take out a line of credit while being a low-income student and I nearly dropped out of school. Because my body was not in congruence with my identity, I could not use locker rooms or restrooms safely, without fear of verbal harassment or even physical assault. This stress affected my ability to be a good student. Eventually, I was able to pay out of pocket for the care I need, but only after a lot of saving, and a lot of time spent educating my insurer and even my doctors. Most people are not so lucky. And even today, I cant access reproductive health care and critical cancer screenings because of exclusions in my insurance plan. My experience was tough, and it was one of the best case scenarios. So many people I know are struggling to make ends meet while paying for their necessary health care out-of-pocket. My bad experience should not be the best case scenario.

55

Sample personal story from a medical provider

My name is Leigh Dolin. Im a past president of the Oregon Medical Association, and a board certified internist. Ive practiced medicine in Oregon for the last thirty years, and for fifteen of those, I took care of transgender patients. Medical care for transgender patients isnt complicated. Gender identity is inherent to who each of us isincluding transgender people. When someone is born with a malformed heart valve, there is no question that we cover the treatment necessary to care for that person. Similarly, there should be no question that when someone is born transgender, we provide the care they need. There are clear standards of care for treatment of a legitimate diagnosis Gender Identity Disorder, or Gender Dysphoria, are recognized medical terms and diagnoses. In fact, the American Medical Association has passed a resolution declaring transition-related care to be medically necessary. In the resolution, they resolved that our American Medical Association support public and private health insurance coverage for treatment of Gender Identity Disorder in adolescents and adults. While caring for transgender patients is straightforward, the discrimination transgender people face is very complex. Because of pervasive misconceptions about what it means to be transgender, many patients have had a difficult time maintaining relationships with their families, friends, and partners, and withstanding the discrimination they faced in society at large. As a doctor, one of the most difficult issues I faced was in ensuring that the care my transgender patients needed was covered by insurance. Coverage of Gender Identity Disorder is excluded from the vast majority of insurance plans, so I had tremendous difficulty providing necessary treatment to my patients within the confines of this exclusion. I can provide a non-transgender woman with hormone replacement therapy, but a transgender woman is prevented from receiving a similar prescription. We can provide a non-transgender woman with a mastectomy, but these exclusions prevent transgender men from receiving the same procedure. No insurance provider that I worked with would cover recommended surgical procedures. Again, as a physician, it is only appropriate for me to determine, in consultation with my patient, what is medically necessary and medically necessary treatment should not be excluded from coverage. Doctors should be able to provide the care our patients need.

56

Sample personal story from a mental health provider

My name is Dr. Adrien Wolmark, Ph.D., Licensed Clinical Social Worker. Ive been working with transgender clients across the U.S. for the past two decades. Currently I work as Director of Counseling Services at NCNM (National College of Natural Medicine.) Throughout my time a mental health professional, Ive consistently worked with transgender patients who were unable to access the care they needed because of insurance exclusions. When I began working with transgender people in the early 1990s, few medical resources existed. And even though there are far more resources today, insurance policies have not caught up and continue to exclude critical care. Being denied access to this care has deep and negative impacts on my transgender clients. They experience suicidal ideation, depression, anxiety, and difficulties in every area of their lives. But when my clients have the care they need, they are more effective workers and community members. In 2008, the American Psychological Association resolved that transition-related care is medically necessary and ought to be covered by insurance. In their resolution the APA Council of Representatives wrote: APA recognizes the efficacy, benefit, and medical necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments With more than 154,000 members, the APA is the largest association of psychologists worldwide. Additionally, the National Association of Social Workers and the American Counseling Association have voiced support for transgender people. From two decades of professional experience to affirmation from large and well-respected associations, its clear that health care for transgender people is medically necessary.

57

Additional Resources
Transgender Health Care Advocacy Resources
Basic Rights Education Fund: The Faces of Trans Inclusive Health Care (Video) http://bit.ly/transhealthvideo Center for American Progresss FAQ: Health Insurance Needs for Transgender Americans http://bit.ly/insuranceneedsfortransamericans Colleges offering Transition related Medical Expenses under Student and Employee Health Insurance http://www.transgenderlaw.org/college/ Human Rights Campaigns: Transgender-Inclusive Health Care Coverage and the Corporate Equality Index http://www.hrc.org/files/assets/resources/Transgender_Healthcare_White_Paper_4.pdf National Center for Transgender Equality Health Care Advocacy Page http://transequality.org/Issues/health.html Open Society Foundations: Transforming Health: International Rights-Based Advocacy for Trans Health http://www.opensocietyfoundations.org/sites/default/files/transforming-health-20130213.pdf Transgender Law Centers: Organizing for Transgender Health Care http://transgenderlawcenter.org/issues/health/orgguide

Transgender Health Programs/Organizations

Center of Excellence for Trans Health/UCSF http://transhealth.ucsf.edu/ Fenway Health http://www.fenwayhealth.org/site/PageServer?pagename=FCHC_srv_services_trans World Professional Association of Transgender Health (WPATH) http://www.wpath.org/

Conferences with health care advocacy workshops

Philadelphia Trans Health Conference http://www.trans-health.org/ Transgender Law Center Leadership Summit http://transgenderlawcenter.org/

58

Notes page

59

60