SALEM, Ore. — Regulators in Oregon and California have quietly directed some health insurance companies to stop denying coverage for transgender patients because of their gender identity.
The states aren't requiring coverage of specific medical treatments. But they told some private insurance companies they must pay for a transgender person's hormone therapy, breast reduction, cancer screening or any other procedure deemed medically necessary if they cover it for patients who aren't transgender.
The changes apply to companies insuring about a third of Oregonians and about 7 percent of Californians, but not to people on Medicare and Medicaid or to the majority of Californians who are insured through a health management organization.
Advocates said the action is a major step forward in their long battle to win better health care coverage for transgender Americans.
"It's just a matter of fairness," said Ray Crider, a 28-year-old transgender man from Portland.
Officials in both states said the new regulations aren't new policies but merely a clarification of anti-discrimination laws passed in 2005 in California and 2007 in Oregon.
Many health insurance policies broadly exclude coverage of gender identity disorder or classify it as a pre-existing condition. Transgender patients are often denied coverage for procedures unrelated to a gender transition, advocacy groups said, because insurance companies deem the condition to be related to their gender identity.
Some transgender patients also have trouble getting access to gender-specific care. A person who identifies as a man might be denied coverage for ovarian cancer screening or a hysterectomy. A transgender woman might be denied a prostate screening. The state insurance regulators said those procedures, if covered for anybody, must be covered for all patients regardless of their gender.
Masen Davis, director of the Transgender Law Center in San Francisco, said he's unaware of insurance regulators in any other state taking similar action.
The California regulations took effect in September and apply only to insurance products regulated by the California Department of Insurance. The agency primarily regulates preferred provider plans that covered about 7 percent of the population in 2010, according to data from the California Health Care Foundation.
The agency that regulates California HMOs has discussed transgender care with health plans, "but no regulations have yet been proposed or adopted," said Marta Bortner Green of the Department of Managed Health Care.
The Oregon Insurance Division issued its guidance in December in a bulletin to insurers. It applies to commercial insurance companies that cover about a third of the state's population.
"This is a very historic bulletin, and it really indicates that the tide is turning on this issue," said Tash Shatz of Basic Rights Oregon, an advocacy group.
Transgender advocates say gender reassignment, through hormone treatment or surgery, is medically necessary, and they've long fought insurance companies that argue the procedures are cosmetic. They say they hope the new state regulations will mean fewer procedures are refused and make it easier to appeal a denial.
State regulators don't have authority to force insurance companies to cover specific procedures, such as hormone therapy or genital reconstruction. But they've told insurers that if they provide breast reduction for patients with back pain, they can't deny it for a gender reassignment that's been deemed medically necessary. Insurers could unilaterally exclude coverage of, say, breast implants, but it would have to apply to all policyholders equally, including breast-cancer patients.
"We are working to ensure that our members' future coverage aligns (with the state memo)," Scott Burton of Regence BlueCross BlueShield of Oregon said.
"We're still assessing the impact of the ruling,," said Kathy Born of LifeWise, another Oregon insurer.