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HHS To Begin Covering Gender Confirmation Surgeries

Friday, May 30, 2014

As Transgender individuals become more accepted within American society, barriers to basic medical care they once faced are falling. The United States Department of Health and Human Services, the government agency that administers the Federal Medicare program announced today they are ending Medicare's decades-old ban on coverage for Gender Confirmation Surgery for transsexual patients. This means that transgender persons who receive Medicare benefits will no longer be automatically denied coverage; instead the decision to cover or not will be made by doctors and medical professionals.

"It's pretty clear there's no basis for the arbitrary discriminatory rule they established in the 1980s when they wouldn't cover it," said Mara Keisling, executive director at the National Center for Transgender Equality (NCTE). "It's not up to bureaucrats anymore. It's up to doctors and patients. It's very important."

The HHS Departmental Review Board is the body that considers appeals to coverage denials from patients. In 2013 they began considering an appeal to the rule, which was adopted in 1989. The rule categorically excluded "transsexual surgery" from Medicare coverage, without regard to the patient's needs or their doctor's assessments. The board issued a preliminary finding in January of 2014, but today's final ruling makes the decision permanent and binding upon the Center for Medicare and Medicaid Services (CMS).

"We have no difficulty concluding that the new evidence, which includes medical studies published in the more than 32 years since issuance of the 1981 report underlying the NCD, outweighs the NCD record and demonstrates that transsexual surgery is safe and effective and not experimental. Thus, as we discuss below, the grounds for the exclusion of coverage are not reasonable," the panel stated.

In a joint statement, the American Civil Liberties Union (ACLU) and the Gay & Lesbian Alliance Against Defamation (GLAAD) said:

"This decision removes a threshold barrier to coverage for medical care for transgender people under Medicare. It is consistent with the consensus of the medical and scientific community that access to gender transition-related care is medically necessary for many people with gender dysphoria. The removal of the exclusion of coverage for surgical care for Medicare recipients means that individuals will not automatically have claims of coverage for gender transition-related surgeries denied. They should either get coverage or, at a minimum, receive an individualized review of the medical need for the specific procedure they seek, just like anyone seeking coverage for any other medical treatment."

The groups brought the challenge on behalf of Army Veteran Denee Mallon, 74. "This decision means so much to me and many other transgender people," she said, "I am relieved to know that my doctor and I can now address my medical needs, just as other patients and doctors do."

Ms. Mallon joined the Army at age 17 and served as a forensics investigator until her honorable discharge, after which she served as a police officer.

Today's ruling does not mean that surgery will be provided to every case. It covers only Medicare patients, and has no effect on private insurers. The decision to approve surgery will be made only after multiple medical professionals provide recommendations and documentation of the the patient's history.

There is no precise figure on how many people this ruling will affect. There has never been an accurate accounting of transsexual people or transgender people (A transgender person is someone who does not completely identify with their gender assigned at birth. Transsexual persons are a subset of this group and includes persons who undergo one or more medical procedures to permanently bring their outward gender presentation in line with their internal sense of self). Williams Institute Demographer Gate Gates has estimated that .3 percent of the Adult American population self-report as transgender, or about 950 thousand American citizens. Other estimates are higher, ranging from .5 percent to as high as 3 percent.

One of the most comprehensive surveys of transgender-related issues, The 2011 National Transgender Discrimination Survey, reported that the most of its study subjects wished to have surgery of some kind, but could not afford it.

“The high costs of gender-related surgeries and their exclusion from most health insurance plans render these life-changing and medically necessary procedures inaccessible to most transgender people,” the report concluded.

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