• Part 1 – ENDA is the Floor


• Part 2 – A Useful Tool


• Part 3 – What the new CEI criteria means


• Part 3a – Transgender Health Benefits

Here's where we stand on transgender benefits currently among companies that participate in the CEI.

These benefits are:
Mental health services
Pharmacy benefits (including hormone therapy)
Medical visits and lab procedures associated with transitioning
Medically necessary surgical procedures
Short-term disability leave

487 companies offer at least one of five-health related benefits
269 of those companies offer two or more benefits
85 cover all five, including GRS

Most companies have benefits plans that cover mental health services and pharmacy benefits.

The new transgender benefits criteria aims to increase the availability of all five benefits areas by:

• Removing transgender exclusion language from benefits plans and insurance coverage
• Ensure coverage of all five areas
• Having at least one benefits plan available to all employees and dependents
• Improving availability and adequacy of care (conformance to WPATH SOC for medically necessary treatment per the 2008 clarification, see www.wpath.org/Documents2/socv6.pdf )

A total of 10 ratings points are available:  5 for baseline criteria and 5 for full criteria coverage.

Baseline requirements

• Insurance contract/documentation explicitly affirms coverage
• Inclusive plan options clearly communicated to employees in plan documents
• Benefits available to “all” are also available to transgender individuals, including for sex affirmation/reassignment
  Short term leave, mental health, Rx, medical consults & labs, reconstructive surgery,
• Routine, urgent, or chronic care appropriate to anatomy regardless of assigned sex (e.g., prostate exam)
• Plan features such as “adequacy of network” or travel/lodging for specialist care applies to transition-related care
• Any applicable dollar caps must meet or exceed $75k per individual

Full Coverage (Baseline plus the following)

• Coverage adheres to widely recognized medical standards (WPATH)
• Covers full range of medically necessary care, per most recent SOC and applicable clarifications (e.g., 2008 WPATH Statement)
• Administration (e.g., “eligibility”) adheres to WPATH guideline for assessment and treatment
• Barriers to care eliminated
• No separate dollar caps or maximums
• Explicit adequacy of network provisions
• No other serious limitations or exclusions

The point structure recognizes that the path to making this happen will likely be different for companies depending on size, regional footprint and local regulation.

Larger companies that can self-insure or "buy in bulk" likely have an easier path forward — like with anything else, the larger the pool the easier to spread the risk.  Larger employers also tend to have regional footprints that make it easier to find insurance carriers or plan administrators that can meet adequacy of care standards.

Smaller firms have a larger actuarial risk and generally less flexibility in plan design or insurance coverage.

Barriers to Care

• Lack of sizable risk pools for small to mid-range companies — as well as the lack of regional insurance carriers that cover GRS and other transition-related procedures — are a big hurdle.
• Caps should be understood as barriers to care for at least some individuals, and especially those for whom more surgical intervention is clinically indicated and medically necessary.
• Finding a good health care practitioner who understands and can follow WPATH SOC — and is "in network" — is a common complaint.
• Reluctance to discuss transition-related treatments impedes negotiating good coverage — as well as perpetuates stigma around transgender issues.  In order to ensure that benefits include necessary care, you need to understand something about that care.
• Myths about cost of care and coverage abound.

Myth #1: Rush to use the benefits

Just because these benefits become availble doesn't mean a mad rush of people transitioning.  The City & County of San Francisco provides the best data to knock this one down.  When the City of SF began covering the whole range of costs related to transitioning in 2001, they expected a large up-tick in new claimants and costs.

The initial cost projections for the city were for $1.75 million per year.  The reality was an average cost increase to the city plan for 2001-2006 of $77,000.

The dollar per claimant (assuming an actuarial 15 claimants) averaged was about $25,000 over the 5 year period.

Because of this, the city — which had originally implemented a surcharge to cover planned cost increases — eliminated the surcharge within the first three years.

I think we can all agree that if the actual utilization rates by the City of San Francisco (which employs somewhere around 30K people with a total insurance pool of 80-100K when you add in retirees) are this low, then there's little to fear.

Utilization rates and costs are low because:

• Not every transgender person wants or requires every covered medical procedure
• Not every medical procedure happens at once, but over time as part of the transition plan
• The total transgender population that might utilize this benefit is small

Here again, if you're not having a full and frank discussion and knowlege about transition-related medical needs (in the context of benefits planning), then myths loom large… not to mention that many people tend to slip into thinking that transitioning only applies on the MTF side of the spectrum.  For those unfamiliar with some of the treatment regimen:

• Hormone Replacement Therapy such as Estrogens (also androgen blockers) & Testosterone, “Growth hormones” (puberty blockers)
• Mental Health Services (clinical diagnosis and counseling
• Surgical Reconstruction (“SRS”) which includes
  Breast/Chest reconstruction
  Facial reconstruction
  Gonadal surgery (e.g., hysterectomy)
  Genital reconstruction
• Other procedures or services
  – Hair removal (electrolysis), speech therapy, prostheses