Coverage for Transgender Services - WPATH Recommendations - OEBB - SEOW February 2, 2021 SEOW Attachment 3 - Oregon.gov
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Coverage for Transgender Services – WPATH Recommendations OEBB - SEOW February 2, 2021 SEOW Attachment 3 willistowerswatson.com
Agenda
Moda has proposed adding coverage for gender confirming facial surgery in OEBB plans
The purpose of today’s discussion is to review broader guidelines and recommendations
for covering medical plan services for members with gender dysphoria in order to
recommend action for inclusion in the renewal
WPATH recommendations
Current carrier coverage guidelines
CCO coverage guidelines
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© 2021 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.WPATH Background
The World Professional Association for Transgender Health is an interdisciplinary
professional and educational organization devoted to transgender health
Mission: To promote evidence-based care, education, research, public policy, and respect in
transgender health
WPATH publishes the Standards of Care and Ethical Guidelines which articulate a
professional consensus about the psychiatric, psychological, medical, and surgical
management of gender dysphoria
Recommendations are endorsed by (not exhaustive):
̵ American College of Obstetricians and Gynecologists
̵ The Endocrine Society
̵ The American Medical Association
̵ The American Psychological Association
Not all plan sponsors or carriers follow or align with WPATH recommendations
Differences in views of evidence-based practices
Balancing cost with coverage
Interpretation of case law
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© 2021 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.Milestones in Transgender Healthcare
The landscape for transgender healthcare services has continued to evolve
over the last 15 years:
2005 – California bans insurance discrimination against transgender patients
2010 – ACA bans discrimination in federally funded health care programs (Section 1557)
2012 – HHS bans marketplace plans from discriminating based on gender identity
2012 – Title VII applies to transgender employees
2014 – The Department of Health and Human Services orders Medicare must now cover
sex reassignment surgery
2016 – All blanket exclusions for gender-affirming care must be removed from HHS
regulated policies
2017 – HHS prohibits any federally assisted insurance plans from wholesale exclusions
of gender-affirming care
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© 2021 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.Summary of Covered and Non-Covered Services
Generally, treatments in the following categories are covered by OEBB’s plans, Oregon
CCO plans, and Moda and Kaiser’s fully-insured plans:
Mental health
Hormone therapy
Breast and chest surgery
Genital surgery
General pre-op, post-op, preventive, and follow-up care
Variation between plans and carriers exists in other major categories as these
procedures are sometimes viewed as cosmetic and/or not medically necessary:
Hair removal/grafts
Facial reconstruction
Body reconstruction/contouring
Voice therapy/treatments
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© 2021 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.A Review of WPATH Recommended Procedures
Book of Book of
OHP OEBB OEBB Business Business
CCO Moda Kaiser MODA Kaiser
Mental health Covered?
Visits for purposes of assessment, diagnosis, referral letters, and treatment of gender
1 X X X X X
dysphoria, transsexualism, or gender identity disorder
Hormones
1 Hormone therapy X X X X X
2 Lab tests to monitor hormone levels X X X X X
Breast/chest surgery
1 Breast augmentation X X X X X
2 Nipple/areola complex reconstruction X X X X X
3 Mastectomy X X X X X
4 Mastectomy with liposuction of the chest wall X X X X X
Genital surgery
1 Penectomy X X X X X
2 Orchiectomy X x X X x
3 Clitoroplasty X X X X X
4 Labiaplasty X X X X X
5 Vaginoplasty X X X X X
6 Urethroplasty X X X X X
7 Scrotoplasty X X X X X
8 Vulvectomy X X X X X
9 Colpectomy/vaginectomy X X X X X
10 Colpocleisis X X X X X
11 Perineoplasty X X X X X
12 Phalloplasty, including glansplasty X X X X X
13 Metoidioplasty X X X X X
14 Hysterectomy / oophorectomy X X X X X
15 Staged (secondary) procedures following phalloplasty/metoidioplasty X X X X X
Secondary procedures (following phalloplasty or metoidioplasty): testicular implants
16 X X X X X
or urethroplasty
17 Secondary procedures (following phalloplasty): penile prosthesis, urethroplasty X X X X X
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© 2021 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.A Review of WPATH Recommended Procedures (Continued)
Book of Book of
OHP OEBB OEBB Business Business
CCO Moda Kaiser MODA Kaiser
Hair removal Covered?
1 Laser X* X X X X
2 Electrolysis X* X X* X
X*
3 Topical anesthetic X X X X
Hair Grafts
1 Hair Grafts
Facial reconstruction
1 Thyroid chondroplasty X X X
2 Brow lift X X X
3 Forehead contouring X X X
4 Malar (cheek) implants X X X
5 Jaw and/or chin re-shaping X X X
6 Lip shortening
7 Scalp (hairline) advancement X X X
8 Rhinoplasty X X X
9 Augmentation thyroid chondroplasty (creation of Adam’s apple for FtM)
10 Chin implant and/or genioplasty X X X
11 Jaw implant X X X
Body reconstruction / contouring
1 Lipofilling of hips, thighs, and buttocks
2 Buttocks implant
3 Mons lift / mons reduction
4 Pectoral implants
5 Calf implants
Voice
1 Voice therapy X* X*
2 Voice modification surgery (only after voice therapy has been proven ineffective)
Initial/pre-op, preventive, and follow up care
1 Initial doctor physical exams, visits, and pre-op tests X X X X X
Post-op follow-up visits with surgeons, primary care providers as needed to ensure proper healing and
2 X X X X X
adjustment
Routine medical care, with periodic lab tests to monitor hormone levels and annual physical exams that are
3 respectful of and attentive to the particular physical make-up of transgender, transsexual, and gender non- X X X X X
confirming bodies
Prescription drugs and any mental health services as an individual prepares for and recovers from gender
4 X X X X X
reassignment surgery
*Indicates additional specific requirements must be met to qualify for coverage
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© 2021 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.Potential Plan Changes
2021-2022 renewal
Moda has proposed covering gender Kaiser Permanente is currently covering
confirming facial surgery for both female facial confirming surgery
to male and male to female reassignment Kaiser Permanente did not provide a
Could include any and several pricing impact as they are in alignment
procedures in the facial reconstruction with the majority of services
category recommended by WPATH
Based on codes recommended by the Coverage for the remaining services is not in
International Facial Gender Symposium, concordance with their clinical practice
including hairline advancement, jaw guidelines
contouring, browlift, rhinoplasty, tracheal
shaving, etc.
Addresses a legal risk identified due to a
lawsuit in administration of another public
plan in Washington state
Estimated cost impact is expected to be
+0.20%
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© 2021 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.Disclaimer Willis Towers Watson shares available medical and pharmacy research and the views of our consultants in our capacity as a benefits consultant. We do not practice medicine or provide medical, pharmacy, or legal advice and encourage our clients to consult with both their legal counsel and qualified health advisors as they consider implementing various health improvement and wellness initiatives When implementing health improvement and wellness initiatives, clients should consider the compliance implications and discuss with their legal counsel and the applicable vendor. If the vendor’s services are offered through an existing medical plan, clients should ensure the terms of the program are properly disclosed to participants in plan materials. If a client offers a HSA-qualifying high deductible health plan, then HSA-eligibility issues should also be considered. If the vendor’s services are offered outside of the existing medical plan(s), then the services being provided must be evaluated to determine whether the program would on its own be considered a group health plan and therefore be required independently to comply with various applicable laws (e.g., ERISA, HIPAA, COBRA, ACA) willistowerswatson.com 8 © 2021 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.
Appendix willistowerswatson.com 8 © 2021 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.
Compliance Considerations
Americans with Disabilities Act (ADA)
Recent case law indicates a split in authority when determining if a transgender individual has a
viable claim under the ADA
̵ Employers should be mindful of the regulatory changes and applicable case law when evaluating
their benefit plan offerings and policies
The EEOC has taken the position that lesbian, gay, bisexual, and transgender individuals may
bring valid sex discrimination in employment claims under Title VII
HIPAA
HIPAA protects individuals’ privacy when it comes to protected health information (PHI), including
information pertaining to a person’s transgender identity and transition
MHPAEA
MHPAEA prohibits group health plans from imposing limits upon mental health and substance
abuse disorder benefits that are not in parity with limits on general medical and surgical benefits
Gender identity disorders (GID) are classified as a mental health conditions, therefore, limits
imposed on GID benefits can trigger implications under MHPAEA
Affordable Care Act, Section 1557 (and Title VII of the Civil Rights Act of 1964)
Section 1557 prohibits health programs or facilities that receive federal funds (known as “1557
covered entities”) from discriminating on the basis of race, color, national origin, age, disability, or
sex, including transgender people
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© 2021 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.
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