by Jason Coon
Health Plan Exclusion Language: Gender Transition Services
As we work with our membership health plans on opportunities to improve moral compliance and Catholic identity, we’ve discovered varying plan language that can be good, but wanted to share a “Better” and “Best” option as well.
Good / Better / Best is a newly created segment of What’s in your Health Plan where we share health plan language options for self funded employer plans who may wish to discuss better language options with their carrier/TPA or their consultant regarding their Catholic health plan. We’d love your feedback on this segment.
This week, we focus on Gender Transition Services.
Good / Better / Best
Provided below are three examples of self-funded health plan exclusion language related to Gender Transition Services rated as Good / Better and explain their deficiencies. We then share an example which incorporates our CBA protections into the exclusion language and demonstrates a “Best” option for consideration.
A good example often is very broad and is typically out of the box, standard, insurance language. The below demonstrates how broad this truly is and often is void of the more fluid gender language of today. This does have some risk exposure if you’re not auditing the full scope of specific services included in Gender Transition Services.
- Good: Sex transformation operations and related services
A better example begins to break out the various areas of where Gender Transition Services fall relating to categories of treatment, drugs, supplies as you can see from the example below.
- Better: Treatment, drugs, medicines, services, and supplies for, or leading to, gender transition surgery.
This better example brings into the language consultation and therapy. This is a critical area for the treatment of Gender Dysphoria. Where this example is lacking is that it doesn’t specifically state Gender Transition Services and only refers to the “changing a Member’s sex”. Because your CBA protections is inclusuive of so much more, and is specific to Gender Transition Services, there is opportunity here as well to expand the exclusion language further.
- Better: Any Medical Supplies, services or charges incurred for consultation, therapy, surgery or any procedures related to changing a Member’s sex.
All of these options, Good or Better, are either too broad or they are missing components of where our CBA member protections provide a stronger and more specific set of procedures and services to exclude.
CBA Protections: Gender Transition Services
Let’s take a look at what CBA protects your organization and your carrier/TPA from by looking at our specific protections.
With respect to gender-transition services, to be adequate, the exclusion must encompass any and all treatments for gender dysphoria, including:
- Gender-transition hormones, cross-sex hormone therapy, and any laboratory testing or other services related to the same
- Gender-transition surgery and/or surgery for treatment of gender dysphoria, including without limitation clitoroplasty, labiaplasty, orchiectomy, penectomy, urethroplasty, vaginoplasty, bilateral mastectomy or breast reduction, hysterectomy, metoidioplasty, penile prosthesis, phalloplasty, salpingo-oophorectomy, scrotoplasty, testicular prosthesis, vaginectomy, and vulvectomy
- Gender-conforming cosmetic surgery
- Psychotherapy for gender dysphoria
Best Option: Getting Specific
Keeping these protections in mind, let’s look at what exclusion language could look like in a “BEST” language option:
Gender Transition Services Exclusion: Treatment, drugs, medicines, services, and supplies for, or leading to, gender transition surgery. Excluded surgeries may include but not limited to: Orchiectomy, Penectomy, Clitoroplasty, Labiaplasty, Vaginoplasty, Mastectomy, Hysterectomy, Vulvectomy, Vaginectomy, Metoidioplasty, Phalloplasty.
Also excluded: Cross-sex hormone treatment, puberty blockers, Gender Affirming Care, and related counseling or Psychotherapy for gender dysphoria**.**
Can you see how this language is much more specific to the protections that your organization has with CBA and gets to the services being rendered as part of the Gender Transition Services performed?
We recommend discussing this language with your carrier / TPA, your consultant, or the CBA as you continue to improve the language of your health plans into the future.
Pre-Authorization Standards
In some conversations we’ve had with Carriers in particular, they are somewhat resistent to getting specific because some of these procedures (mastectomy and hysterectomy) are medically necessary and covered benefits. It’s important to guide them to their pre-authorization standards and how these should only deny in cases where the diagnosis is related to gender dysphoria/gender transition.
CAUTION: Is Silence Good Enough?
If your health plan is silent on Gender Transition Services, you should ask your carrier / TPA how they are administering all the services included as part of this growing list of services and arrange for audit measures to ensure the plan does not cover ongoing. Just because something is silent within a plan does not mean it is not being covered.
CBA has uncovered several silent benefits being covered by our member’s health plan carriers. For more information on this, I recommend reading this article on our Healthcare Insights Blog.
Case Study: The Hidden Risks of Silent Exclusions
If you are interested in learning of more challenges and risks associated with silent exclusions, please contact the CBA for a copy of our case study developed through our detailed review process, carrier audits, and consultant discussions.
Taking Advantage of your FREE CBA Services
We continue to demonstrate the nuance in these health plan language differences and why they are important. If your goal is to further improve your Catholic Identity within your health plan experience or organization, please contact Jason Coon at the CBA for a free health plan review and moral compliance analysis.
As today’s legal attacks shift into our religious identity, it’s critical to take the essential steps in protecting your organization. Your identity is another layer of protection that should be prioritized, and we are here to help.