Presented at Enroll America's 2016 State of Enrollment conference.

1. Times of Change:
The Latest Dynamics in LGBT Outreach,
Enrollment and Coverage

2. www.Out2Enroll.org
Times of Change: The Latest
Dynamics in LGBT Outreach,
Enrollment, and Coverage

3. www.Out2Enroll.org
Session Goals
1. Describe the latest updates on LGBT enrollment and
related policy
2. Identify key strategies for reaching out to LGBT
communities
3. Identify key strategies for making sure your organization
is prepared to effectively work with LGBT people
4. Identify key coverage concerns for LGBT communities
and describe strategies to address them

4. www.Out2Enroll.org
What is LGBT?
• LGBT: Lesbian, Gay, Bisexual, Transgender
• Sexual orientation:
- Heterosexual or straight
- Gay or lesbian
- Bisexual
• Gender identity: Each person’s deeply felt, internal
knowledge of their own gender
• Transgender: A person whose gender identity is different
from that typically associated with their assigned sex at birth

5. www.Out2Enroll.org

6. www.Out2Enroll.org
1 in 4 low- and middle-
income LGBT people are
uninsured.

7. www.Out2Enroll.org

8. www.Out2Enroll.org
How many provisions of the Affordable
Care Act (statute or regulations) deal with
discrimination against LGBT people?
A. None
B. Two
C. Four

9. www.Out2Enroll.org
LGBT Nondiscrimination in the
Affordable Care Act
 ACA Section 1557 – Health system nondiscrimination
 PHSA Section 2702 – Guaranteed issue
 ACA Section 1302 – Essential Health Benefits
 ACA Section 1311 – Qualified Health Plans & Marketplaces

10. www.Out2Enroll.org
ACA Section 1557 Proposed Rule
 Bans discrimination on the basis of sex, including gender
identity and sex stereotyping
 Requires coverage for and provision of medically
necessary services for trans people
 Requires trans people to be treated in accordance with
their gender identity in, e.g., hospital room assignments
 Plans must cover preventive services regardless of
gender or gender identity
 Bans categorical transgender insurance exclusions

11. www.Out2Enroll.org

12. www.Out2Enroll.org
The State of Marriage Equality

13. www.Out2Enroll.org
LGBT Pride
Month is
coming up in
June!

14. www.Out2Enroll.org
Email info@out2enroll.org to get trained &
listed in Out2Enroll’s assister locator tool

15. Strategies for improving LGBT
enrollment and coverage
Lois Uttley, MPP
Co-Chair LGBT Task Force
Health Care for All New York
Enroll America national conference
May 12, 2016

16. LGBT Task Force of Health Care for All NY
• HCFANY: A statewide coalition of more than 170 advocacy
organizations working to achieve quality, affordable health
care for all New Yorkers.
• The LGBT Task Force includes organizations serving LGBT
New Yorkers. Current priorities include:
– Changing the NY State of Health marketplace application to include
sexual orientation and gender identity questions
– Improving insurer compliance with NYS policy requiring coverage of
all medically-necessary treatment for gender dysphoria.

17. Why the enrollment application is not LGBT friendly
• The gender question is the second
question on the application and
has only two answers: male or
female.
• Enrollees who are transgender
may be unsure how to answer the
question.
• Enrollees who do not identify as
male or female (are gender non-
conforming) may not feel
comfortable continuing to fill out
the application.
• There is no demographic question
collecting data on sexual
orientation.

18. What we tried previously
• The LGBT Task Force won the addition
of “help text” to the NYSOH
marketplace application to guide
applicants in answering the binary
(male/female) gender question:
– “The gender you report here must be the
same as what is currently on file with the
Social Security Administration.”
• Problems with this guidance
– This does not help enrollees who do not
have a Social Security Number
– The question does nothing to accurately
record an enrollee or an enrollee’s family
as LGBT.

19. We propose to change the gender question
• The HCFANY LGBT Task Force asked NYSOH to
amend the gender question to read this way:
– Gender:
• Male
• Female
• Transgender: male-to-female
• Transgender: female-to-male
– What was your sex assigned at birth?
Help Text: “The sex you report here is the sex on your original
birth certificate or sex assigned to you at the time of birth.”
• Male
• Female

20. What would this new 2-step gender
question accomplish?
• It would allow collection of transgender demographic
data for health planning purposes and improve the
enrollment experience for transgender people.
• The preferred gender marker would be reported to the
insurer for official records:
– Those individuals answering male or transgender male to
the gender question would be reported as male.
– Those individuals answering female or transgender female
to the gender question would be reported as female.
– But the sex-assigned-at-birth answer would be available as
back-up data to help avoid denials if an individual seeks
sex-specific services (such as pap smears and prostate
exams) that do not match his/her official gender marker.

21. Sexual Orientation Question
• The LGBT Task Force recommended adding this
question:
– Do you think of yourself as …
• Heterosexual or straight
• Homosexual, gay or lesbian
• Bisexual
• Other (write in)
• The sexual orientation question would be listed in
the optional demographics section, where
questions about race and ethnicity appear.

22. Status of requested application changes
• NYSOH officials have voiced their willingness to
make these changes.
• However, they believe they need CMS approval to
change the application.
• Requests to CMS from the LGBT Task Force and
allies in other states, and at the Center for
American Progress, have not won approval.
• We plan to ask our U.S. Senate and Congressional
representatives to make this request of CMS.

23. NY is among the states requiring
coverage of transgender health care

24. New York advocacy on transgender
coverage in private health plans
• In February 2014, LGBT Task Force asked NYS
Department of Financial Services (DFS) to require all
private insurers under its jurisdiction to bar exclusion
of transgender coverage and discrimination against
transgender individuals
• DFS issues a Circular Letter in December 2014 requiring
private health insurance plans in New York State to
cover all medically necessary care for treatment of
gender dysphoria.
• (Medicaid coverage is governed by separate agency.)
• By spring 2015, the LGBT Task Force had received
complaints that not all insurers were complying.

25. LGBT Task Force organizes 3 listening
sessions around the state
• Listening panel was made up of four people
-- two representatives from DFS and two
representatives from the LGBT Task Force.
• A roundtable format was used, rather than a
formal hearing.
• Local LGBT organizations were invited. All
sessions were closed to the press, and
individuals testifying were assured their
identities would be protected.
• Each session lasted 2 hours. NYC and Albany
sessions were hosted at DFS office
locations. The third session was conducted
by conference call with participants from
Rochester.

26. Exclusions and internal coverage
guidelines still a problem
• Transgender exclusions are still
present in some insurance
policies, ruling out coverage for:
– “Sex transformation procedures”
– “Transsexual surgeries”
– “Sex Change Procedures”
– “Gender reassignment surgery”
• Even when no explicit exclusions
are found in policy statements,
insurers’ internal Coverage
Determination Guidelines (CDGs)
lead to denials.

27. Coverage denials are caused by gender
marker discordance
Transgender individuals are
being denied coverage due to
their gender marker not
matching a “sex specific”
service.
• Transgender man was covered
for PEP after a recent sexual
encounter, but was denied
coverage for Plan B because of
his gender marker.
• Transgender man who had not
changed his gender marker
was able to get PEP and Plan B
covered with no trouble.

28. Insufficient network adequacy
– Lack of in-network providers, particularly surgeons
– Insurer recommendation of in-network providers
who are not qualified in transgender care
– Insurer reluctance to create one-time in-network
exception contracts with out-of-network providers
– No coverage for travel expenses incurred going to
an in-network provider located far away.

29. Poor communications by health plan
representatives
• Insufficient insurance representative training
– Many transgender individuals find out about their
coverage for transgender care through insurance
representatives.
– Insurance reps may incorrectly say that there is an
exclusion in the policy, even though DFS letter to
insurers bars such exclusions.
– Many transgender individuals give up on seeking
out coverage after these discouraging or confusing
communications with insurance representatives.

30. Non-binary individuals encounter
problems meeting coverage guidelines
• Inaccessible care for non-binary individuals
– Many of the insurers’ internal coverage determination
guidelines (CDGs) frame medical transition as transitioning
from one gender to “the other,” assuming that gender
identity is binary.
– Some CDGs require verification that the individual seeking
gender transition services (hormones or surgery) has had a
“real life experience” in the desired gender for 12 months.
This requirement is virtually impossible for non-binary
individuals to fulfill.
– Medical and mental health providers must write referral
letters to fit their patients into the confines of male or
female to get access to coverage, rather than write a letter
of support for services without a binary gender structure.

31. Task Force recommendations for
improving insurer compliance
1. Requiring insurers to re-issue plan documents, removing
exclusions and explicitly stating they cover gender
transition services.
2. Telling insurers they may not deny services or medications
on the basis of an individual’s gender marker alone.
3. Create requirements for qualified, in-network providers,
as most plastic surgeons are not trained to perform
gender affirming surgeries.
4. Work with insurers to get them to allow out-of-network
access (via in-network exceptions) for individuals who do
not have sufficient in-network access and require insurers
to cover the cost of travel associated with seeing these
providers.

32. Improving communications about
transgender coverage requirements
6. Develop and provide model
insurance representative
training materials to insurers.
7. Conduct a public education
campaign for transgender
and gender non-conforming
New Yorkers about their
health care rights, the
benefits that must be
covered by qualifying
insurance policies and how
to appeal a denial of
coverage.

33. Questions and follow-up?
• Feel free to contact Lois Uttley, Co-Chair of the
LGBT Task Force of Health Care for All NY at
lois@mergerwatch.org or 212-870-2010
• For specific expertise on transgender coverage
problems, contact Ali Harris, the LGBTQ
Program Association at Raising Women’s
Voices-NY, at Ali@mergerwatch.org or 212-
870-2010.

34. © 2016 Enroll America | StateOfEnrollment.org
Thank You!
Lois Uttley, Director, Raising Women’s Voices
Lois@mergerwatch.org
Kellan Baker, Steering Committee Member, Out2Enroll
Kellan@out2enroll.org
Lori Gum, Program and Pride Coordinator, Stonewall Columbus
Lgum@stonewallcolumbus.org
Rebecca Billy, Benefits Specialist/Navigator,
University of Central Arkansas
Billy@uark.edu