VA provides health care for transgender patients, including
those who present at various points on their transition from
one gender to the next. This applies to all Veterans who are
enrolled in VA’s health care system or are otherwise eligible
for VA care, including those who have had sex reassignment
surgery outside of VHA, those who might be considering
such surgical intervention, and those who do not wish to
undergo sex reassignment surgery but self-identify as transgender. Intersex individuals may or may not have interest
in changing gender or in acting in ways that are discordant
with their assigned gender.
The major insurance companies do not cover transgender surgery
for individuals who are in “fully insured” health plans i.e. where the
insurance company bears the risk. But there are some 200 “self-funded” employers who will include this benefit as they are bearing the
costs directly such as Shell Oil and Campbell Soup. Additionally
Massachusetts, California and such municipal governments as San
Francisco; Seattle; Portland, Ore.; and the District of Columbia
provide coverage of transgender surgery for their employees and
dependents.
The government represents large payer groups that have also
taken variable positions. In May 2014, Medicare began covering
transgender surgery and medical treatment after a Department of
Health and Human Services appeal board reversed long standing
policies that considered such surgery as cosmetic. (http://www.
hhs.gov/dab/decisions/dabdecisions/dab2576.pdf) This was considered a huge victory for the transgender community. However
the individual Medicare beneficiary must obtain a letter of medical
necessity from his or her mental health professional or primary
care professional to show the surgery is necessary. The impact to
Medicare is not considered to be too great as current estimates
place the incidence of transgender individuals at 0.3 percent of the
US populations. The costs for uncomplicated surgery are around
$50,000, while hormone replacement can be $50 to $100 a month.
Medicare Advantage health plans are obligated to follow CMS, so
would be subject to the same rules.
With the new benefits in the ACA legislation, Medicaid is now
larger than Medicare. However, Medicaid coverage of gender reassignment is provided fully only in California, Vermont and now
in the District of Columbia. Oregon Medicaid has some limited
benefits. Massachusetts is expecting Medicaid coverage. Even as
close as Indiana, there is coverage for intersex surgery in Medicaid
for children with ambiguous genitalia.
When there is coverage, the standards are typically those developed by the World Professional Association for Transgender
Health (WPATH), an international society of physicians, health
professionals and lay people who have promulgated standards and
helped individuals find physicians who will treat them. The “Typical
Benefits” see below, are derived from their standards.
While we have seen integration of other groups into population,
the transgender group is one of the last remaining minority groups.
It is also one with significant issues with anxiety, but rarely with true
cognitive disorders. Physicians managing these patients can help
with understanding their benefits. If there is coverage for surgery
and medications that can help the individual express the gender
with which the individual identifies.
The patient with Gender Dysphoria may present to the primary
care physician with a number of minor symptoms as a way understanding how open that doctor would be to discussing transgender
issues. Certainly the best approach is supportive and non-judgmental. There are some resources in Louisville although more in
larger communities.
The University of Louisville website includes its Color of Health
page which does have some local useful resources. It is found at:
http://louisville.edu/nursing/colorofhealth/lgbt. But as with other
cities of Louisville’s size, there are no transgender specific resources.
The primary care physician may need to recognize the multiple needs
a patient has in meeting the goal of achieving the genetic phenotype
of their self-identit 丁