Aetna Updates Policies to Cover Transgender Feminizing Surgeries

Aetna has updated its coverage policies to correct care disparities and to include gender-affirming surgeries for transgender women in most of its commercial plans, CVS Health announced.

Aetna worked with the Transgender Legal Defense & Education Fund (TLDEF), the law firm Cohen Milstein Sellers & Toll (Cohen Milstein), and individual transgender Aetna members in order to redesign the payer’s clinical policies around transgender surgeries.

The alterations cover transfeminine breast augmentation as a medically necessary clinical service, when certain criteria have been met.

“Our decision to update our clinical policy bulletin is consistent with many changes we have made over the years to better serve the needs of the LGBTQ community,” said Jordan Pritzker, MD, senior director of clinical solutions for Aetna.

“We appreciate the collaborative nature of this process, which allowed us to make an evidence-based change to our coverage policies regarding important care for members of the LGBTQ community.”

Aetna members motivated this policy change. A total of four transgender women came to TLDEF and Cohen Milstein when Aetna denied coverage for their breast augmentation.

TLDEF and Cohen Milstein then approached Aetna to promote changes to the policies that prevented the four Aetna members from receiving coverage for their treatments.

“My hope is that being part of this groundbreaking collaboration helps other transgender and non-binary people have access to the health care we deserve,” said Nancy Menusan, an Aetna beneficiary who pushed for this change.

“By dropping exclusions for medically-necessary care like top surgery, Aetna is paving the way and setting an example for other health insurance providers, and I hope others will take note.”

In order for Aetna members to receive coverage for the treatment as medically necessary—as opposed to an aesthetic, elective surgery—, the new criteria seek to establish that the member suffers from gender dysphoria.

The American Psychiatric Association defines gender dysphoria as “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.”

Under the adjusted policies, the member must have a letter of referral from a mental healthcare provider. The member must also offer evidence of their history with gender dysphoria, demonstrating that it has been a prolonged condition. Additionally, members should have already completed a year’s worth of hormonal therapies before they receive the surgery.

“This marks an important moment for transgender women, who are increasingly speaking out to demand better support for their physical and mental health,” said Kalpana Kotagal, partner at Cohen Milstein.

“Aetna has a history of ensuring health care coverage for the transgender community, and we appreciate its cooperation in revising this policy to enhance medical coverage for transgender women who suffer from gender dysphoria.”

TLDEF also affirmed Aetna’s decision.

“Aetna has been an industry leader in providing access to medically-necessary, transgender-related health care coverage, and we commend them for continuing to lead by example,” said Andy Marra, executive director at TLDEF.

“Eliminating this exclusion is a vital step towards providing comprehensive and medically-necessary care that all transgender people deserve to ensure their health and wellbeing.”

Many changes are taking place in the healthcare industry as it reforms its approach to healthcare for the LGBTQ+ community.

The payer industry at large was vocal about certain nondiscrimination changes that the Department of Health and Human Services (HHS) made under the Trump administration. Payers found that changes that HHS made to the language in the Affordable Care Act Section 1557 stripped away many of the protections against gender and sexual discrimination.

Employers are also changing their policies regarding healthcare benefits for the LGBTQ+ community. Seventy-four percent of employers that offered heterosexual spousal coverage also offer same-sex spousal coverage in 2020, a Kaiser Family Foundation brief discovered.

Nevertheless, studies show that there are still many care disparities between healthcare coverage and services for the LGBTQ+ community as opposed to the heterosexual community in the US.

“We find that, as of mid-2020, while employer offer of same-sex spousal coverage has increased over time, it remains less common than opposite sex spousal coverage,” stated the same Kaiser Family Foundation brief on employers’ changing benefits. 

A separate study published on the JAMA Network Open found that qualified health plans on Affordable Care Act marketplaces have more prior authorizations on HIV treatments in the southern states than elsewhere in the US.

Nearly 40 percent of health plans on the individual health insurance marketplace in the South had prior authorizations on PrEP therapies, as opposed to 2.3 percent in the Northeast.

“This finding is concerning for possible discriminatory benefit design (benefit design that prevents or delays people with complex or expensive conditions from obtaining appropriate treatment) because prior authorization is being used differently depending on the QHP’s region,” the study stated.