Trans Health Care: How to Get What You Want Nico Quintana Policy Director Phoenix Singer, Policy Fellow Trans Health Care Oregon

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Trans Health Care Oregon Our Mission: Basic Rights Oregon will ensure that all lesbian, gay, bisexual, transgender and queer Oregonians experience equality by building a broad and inclusive politically powerful movement, shifting public opinion, and achieving policy victories.

Basic Rights Oregon’s Trans Justice program works to win policies that increase the safety and well being of transgender Oregonians. We do this by increasing the safety of trans people within prisons and jails, working to fully educate our communities about and enforce Oregon’s ban on discrimination, and increasing access to health care for trans Oregonians. Trans Justice Program Trans Justice Working Group

Effective Jan 1,2015, the Oregon Health Plan includes coverage for Gender Dysphoria. Predominantly based on the World Professional Association of Transgender Health (WPATH) standards of care version 7. Trans Health Care Oregon

Covered Services –Counseling –Hormone therapy –Primary care visits –Special doctor visits –Mental health care visits –Gender affirming hormone therapy –Puberty suppression –Anti-androgens –Lab work –Some surgeries Trans Health Care Oregon

Providers follow WPATH standards with some exceptions. Must work with mental health provider to receive a diagnosis of Gender Dysphoria Must work with medical providers to determine what is medically necessary. Trans Health Care Oregon

Requirements To Access Hormone Therapy? Have persistent, well-documented gender dysphoria Have the capacity to make a fully informed decision and to give consent for treatment under Oregon law Have any significant medical or mental health concerns reasonably well controlled Have a thorough psychosocial assessment by a qualified mental health professional with experience in working with patients with gender dysphoria Trans Health Care Oregon

Sex reassignment surgery requirements: Have documented gender dysphoria Have completed 12 months of continuous hormone therapy Have completed 12 months of living in a gender role that is congruent with their gender identity Have the capacity to make a fully informed decision and to give consent for treatment under Oregon law Have any significant medical or mental health concerns Have two referrals from qualified mental health professionals. Trans Health Care Oregon

Navigating OHP (Medicaid) 1.Start with your primary care provider to begin process to access benefits. 2.Call CCO member services if you encounter problems getting access to covered benefits. 3.Contact Basic Rights Oregon with denial assistance. 4.For discrimination complaints contact OHA Office of Equity and Inclusion and Basic Rights Oregon. Trans Health Care Oregon

Medicare Coverage Seniors & Certain Disabilities 1989 – adopted National Coverage Determination categorically excluding of “Transsexual Surgery” coverage Exclusion regardless of individual medical conditions or needs 2014 – the 1989 exclusion eliminated; deemed outdated, incomplete, and biased 2014 – current: transition-related care covered Trans Health Care Oregon

Covers routine preventative care, medically necessary transition related care Prescriptions covered under Part D prescription drug plan formularies Covers medically necessary surgeries (no national exclusion) Trans Health Care Oregon Medicare Coverage

Medicare (Part A & B) Center for Medicare and Medicaid Services (CMS) approved special billing code (condition code 45) to process claims (KX modifiers) If denied, request written “coverage determination” Request must be submitted w/ doctor’s statement explaining medical necessity (and any supporting documentation) For RXes – use “Model Coverage Determination Request” form Trans Health Care Oregon

Medicare Appeals (Part A & B) Must appeal within 120 days – “Redetermination” is first level of appeal You, your doctor, caregiver, friend, etc can advocate for you to the company handling your plan Usually take approximately one week for decision Trans Health Care Oregon

Private Medicare (Medicare Advantage, Medicare Cost Plus, Medicare Part D, etc) Should cover transition-related care If denied, request written “coverage determination” Request must be submitted w/ doctor’s statement explaining medical necessity (and any supporting documentation) For Rxes – use “Model Coverage Determination Request” form Trans Health Care Oregon

Medicare Appeals Cannot use “condition code 45” Similar to original Medicare Must submit appeal to plan Appeal within 60 days of denial in writing Trans Health Care Oregon

Private Insurance In 2013, Oregon’s Insurance Division of the Department of Consumer and Business Services (DCBS) was the first state in the nation to announce that insurance companies doing business in Oregon must end discriminatory exclusions of medically necessary healthcare for transgender Oregonians. Trans Health Care Oregon

Trans Health Care Bulletin Health insurers may not categorically exclude transgender patients from coverage. Health insurers must provide coverage and cannot deny coverage of treatments for transgender policy holders if the same treatments are covered for other policy holders. Health insurers may not deny treatment on the basis of a policy holder’s actual or perceived gender. That means that all policy holders can rely on annual exams, cancer screenings, and gender-specific health care, regardless of their gender on file. The statewide mandate for coverage of mental health services must apply to transgender patients. Trans Health Care Oregon

Private insurance issues The bulletin did not result in all insurance plans covering transgender health care services. More advocacy is necessary to obtain policy victories. Trans Health Care Oregon

Transgender surgery riders What are riders? OEBB, PEBB, Multnomah County Employees What is covered? Hormones, counseling, some surgeries. Caps and limits--most riders have a lifetime cap of $75,000 for care. Trans Health Care Oregon

Navigating Private Plans Call the Insurance Division Troubleshoot denials! File complaints if you are told your plan does not cover trans healthcare services. Oregon Insurance Division’s Consumer Advocacy Hotline: Trans Health Care Oregon

Other Providers and Resources Trans Health Care Oregon Oregontranshealth.com Transmedicare.com Basic Rights Oregon PSU’s Queer Resource Center OHSU The Q Center TransActive Gender Center

Join the Campaign! –Take a photo at the booth –Sign a postcard –Share your story –Participate in the USTS –Volunteer Advocate for you and your community! Appeal denials and help others do the same! Trans Health Care Oregon