The state’s largest private insurer will now cover gender-affirming facial surgery and other services, after advocates challenged its denying coverage for two transgender women.
Blue Cross and Blue Shield of North Carolina updated its Gender Affirmation Surgery and Hormone Therapy policy July 1 to state that facial surgeries for feminization or masculation, voice lessons and other services are medically necessary. The change now covers those procedures and services if they are allowed under the patient’s health benefit plan.
“Transgender health care is medical health care,” said Kathryn Vandegrift, a 28-year-old Blue Cross customer who was initially denied coverage for facial surgery. “And health care is a human right, nobody should be denied.”
Vandergrift, who lives in western North Carolina, another woman and two North Carolina nonprofits, Equality North Carolina and the LGBTQ Center of Durham, sought the change from Blue Cross, which serves nearly 4 million customers.
The procedures outlined in the Blue Cross policy help treat gender dysphoria, which the American Psychiatric Association defines as psychological distress resulting from “an incongruence between one’s sex at birth and one’s gender identity.”
Gender affirmation surgery, which involves multiple medical, psychiatric and surgical procedures and services, is one treatment for gender dysphoria, the policy states.
Blue Cross has long recognized gender dysphoria as a medical condition and has covered related treatments, the insurance company said in a statement.
The July 1 update “expanded coverage on treatments that are medically necessary as part of the overall treatment plan for gender dysphoria,” the statements said.
The change followed an ongoing review process of the policy by practicing physicians, the statement said.
“While the Transgender Legal Defense & Education Fund (TLDEF) highlighted this issue for our attention, the review was conducted independently from these discussions,” the statement said.
One in four transgender people had experienced a health insurance problem in the last year, including being denied coverage for transition procedures and routine care, according to the 2015 U.S. Transgender Survey, one of the largest survey of transgender people in the U.S.
More than half had been denied coverage for transition-related surgery.
‘A safety issue’
Noah Lewis, Trans Health Project director for the TLDEF, said gender affirming health care is critical for transgender people’s health and their safety.
Like most significant medical procedures, facial surgery is expensive. A small percentage of people may be able to pay out-of-pocket, but others might take on significant debt or cash out their retirement.
Without facial surgeries and voice lessons, some people live in limbo, are often misgendered and live in fear of being recognized as transgender, Lewis said.
“It presents a safety issue to be visually transgender, especially in the South,” he said.
“They are afraid to leave their house. They are afraid to go to the gym, apply for jobs, go to school,” Lewis said. “They are just held back in every area of their life because they are not able to get this basic form of medical treatment, and the only reason it’s being excluded is that it’s related to being transgender.”
Blue Cross is the latest in a series of health insurance companies updating their policies, Lewis said.
Aetna and Antham have also expanded their coverage.
In May, the Biden administration reversed a Trump-era policy that excluded transgender people from protection against sex discrimination in health care.
“It is important for people to know that these types of denials and exclusions are unlawful and there is legal recourse,” Lewis said.
In general, transgender people face multiple challenges to health care, including cost and providers who lack insufficient knowledge, The Charlotte Observer reported.
The TLDEF is also part of an ongoing 2019 lawsuit filed by state workers who are transgender or who have transgender children contending the State Health Plan discriminates against them, The News & Observer reported.
The health plan, which insures more than 700,000 state employees, doesn’t cover costs related to gender dysphoria.
‘A devastating experience’
Vandegrift said she came to accept her need for gender transition in 2018 and started working on a plan.
More than a year ago, she started looking over her insurance plan, which she had through a private employer. She realized there was a categorical exclusion for facial surgeries.
Vandegrift contacted the TLDEF, which helped her navigate the process of seeking claims, filing appeals when they were denied and other actions.
The process was devastating, she said.
“It is just the repeated bureaucratic denial in this harsh language of asserting that who I am and what I need is not actually medically necessary,” she said.
Not getting gender-affirming treatment makes her and others’ bodies hard to live in, she said. It also makes the world uncomfortable and often unsafe, she said, because she doesn’t know how people will react if they realize she is a transgender woman.
After the policy change, Vandegrift was scheduled to have facial surgery this week.
She’s excited about the change and moving forward.
“I might be able to move past that and live fully as myself,” she said.
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