Health Care | Transition-Related Care | Vermont
Can health care plans discriminate against LGBTQ+ people?
In general, under federal and Vermont state law, nearly all health plans cannot discriminate on the basis of sex, and, because the Supreme Court ruling in Bostock v. Clayton Co. concluded that all gender identity and sexual orientation discrimination is a form of sex discrimination, nearly all health plans cannot discriminate against LGBTQ+ people.
What health care plan protections are provided by Vermont?
Vermont Department of Financial Regulation Division of Insurance
In 2019, the Department of Financial Regulation issued a bulletin requiring that health plans regulated by the Department must cover medically necessary treatment for gender dysphoria and related health conditions.
The bulletin states that health plans “shall not exclude coverage for medically necessary treatment including gender affirmation surgery for gender dysphoria and related health conditions. In addition, insurers may not deny coverage of gender affirmation surgery as not medically necessary on the basis of age without other clinical factors or circumstances supporting the decision.”
In 2019, The Legislative Committee on Administrative Rules voted to approve a new rule for Vermont Medicaid that requires coverage for medically necessary surgery for the treatment of gender dysphoria. For more information, visit the Agency of Human Services Health Care Administrative Rules Gender Affirmation Surgery for the Treatment of Gender Dysphoria.
Are there any health care plans that are not protected under Vermont law?
Yes. Medicare and employer health plans that are self-funded (also known as self-insured) are governed by federal law.
What health care plan protections are provided by the federal government?
In 2013, Medicare removed the ban on coverage for the treatment of gender dysphoria because it was “experimental” and began to cover medically necessary treatment for gender dysphoria.
Section 1557 of the Affordable Care Act (ACA)
Section 1557 makes it unlawful for any health care provider that receives funding from the Federal government to refuse to treat an individual– or to otherwise discriminate against the individual– based on sex (as well as race, color, national origin, age, or disability). Section 1557 imposes similar requirements on health insurance issuers that receive federal financial assistance. Healthcare providers and insurers are barred, among other things, from excluding or adversely treating an individual on any of these prohibited bases. The Section 1557 final rule applies to recipients of financial assistance from the Department of Health and Human Services (HHS), the Health Insurance Marketplaces, and health programs administered by HHS.
Section 1557 generally does not apply to self-funded group health plans under ERISA or short-term limited duration plans because the entities offering the plans are typically not principally engaged in the business of providing health care, nor do they receive federal financial assistance.
In May 2021, the Biden Administration announced that the Health and Human Services Office for Civil Rights (OCR) would interpret and enforce Section 1557 of the ACA and Title IX’s nondiscrimination requirements based on sex to include sexual orientation and gender identity. The update was made in light of the June 2020 U.S. Supreme Court’s decision in Bostock v. Clayton County and subsequent court decisions.
In enforcing Section 1557, OCR will comply with the Religious Freedom Restoration Act, 42 U.S.C. § 2000bb et seq., and all other legal requirements and applicable court orders that have been issued in litigation involving the Section 1557 regulations.
For employers with 15 or more employees, Title VII bans discrimination on the basis of race, color, religion, sex, and national origin in hiring, firing, compensation, and other terms, conditions, or privileges of employment. Employment terms and conditions include employer-sponsored healthcare benefits. Historically, not all authorities have agreed that Title VII protects LGBTQ+ workers against discrimination.
However, the Supreme Court decision in Bostock v. Clayton Co. changes this because that ruling made it clear that sexual orientation and gender identity discrimination are forms of sex discrimination. Although the decision is about wrongful employment termination, it has implications for employer-sponsored health plans and other benefits. For example, employers may want to adjust group health plan coverage of gender dysphoria and related services, including gender-affirmation surgeries, and review and compare benefits for same-sex and different-sex spouses.
Can religious employers discriminate against LGBTQ+ people?
On July 8, 2020, in Our Lady of Guadalupe School v. Morrissey-Berru, the United States Supreme Court reaffirmed its stance on the application of a ministerial exception to employment discrimination cases as established in earlier rulings. In doing so, the Court simultaneously raised an unanswered issue under Title VII: does the ministerial exception for religious employers allow those organizations to discriminate against employees or candidates based on their LGBTQ+ status?
It’s unclear at this point how the Court’s ruling in Our Lady of Guadalupe School v. Morrissey-Berru may impact the LGBTQ+ employees of religious employers, but religious organizations and employers should recognize that the ministerial exception does not apply to every position within their organizations. Rather, it is limited to those employees who truly perform religious duties. For example, the position of a school janitor who is only present in the building outside of school hours and is not responsible for transmitting the faith would likely not be considered ministerial in nature.
What steps can I take to get coverage for treatment of gender dysphoria?
- First, check to see if your health plan provides coverage for the type of treatment that you want by getting a copy of the plan’s “Summary of Benefits and Coverage.”
- Most insurance plans, both public and private, have detailed requirements that must be met in order to obtain coverage. This is particularly true if you are trying to obtain coverage for transition-related surgery. So, contact your health plan and request a copy of the requirements for the treatment you are seeking.
- Work with your therapists and doctors to make sure that you satisfy all the health plan’s requirements. Documentation from your therapists and doctors is the most critical factor in determining whether your treatment request will be approved.
- Check what treatment requires pre-approval. In most cases, any surgery will require pre-approval, and the plan may only pay if you use a surgeon that takes their plan.
- If your treatment request is denied, find out the reasons for the denial, and, if you still think that you qualify for the treatment, follow the plan’s appeal process. Usually, there will first be an internal appeals process, and, if you are not successful there, you can sometimes appeal to an outside agency. Make sure that you adhere to the deadlines—failure to meet a deadline can automatically end your ability to appeal.
- Keep GLAD informed if you are denied treatment. GLAD may be able to offer suggestions that can help you win your appeal. You can contact GLAD Answers by filling out the form at GLAD Answers or by phone at 800-455-GLAD (4523).
- Although more health plans now cover treatment for gender dysphoria, the process for obtaining treatment, particularly for transition-related surgery, can be time-consuming and frustrating. A great deal of documentation is required and finding a surgeon that does the type of surgery, and who is also acceptable to the health plan, can be difficult.
- Don’t be afraid to be persistent and to refile if you are denied.
How do I find a surgeon who will take my health insurance?
More and more surgeons who perform sex reassignment surgeries take health insurance. You should research surgeons carefully to find one who is a good fit for you. You can look at the list of in-network providers provided by your plan to see if they are included or if it includes any surgeons in your area, and if not, you can contact the surgeon’s office to determine if they accept your insurance. Most health insurance plans require that you use a medical provider in your network, but if your network does not include a surgeon who performs the services you need, you may be able to go out of network if you seek prior authorization from your plan.
What should I do if I am being discriminated against in healthcare?
If you are being discriminated against by a healthcare facility or provider, you can file a discrimination complaint with the Vermont Human Rights Commission. Visit the Discrimination Issue Area for detailed information about how to do this.
If you have a health care plan that is regulated by the Department of Financial Regulation, you can file a complaint with that department: Insurance Complaints | Department of Financial Regulation.
If you have a health care plan that is governed by Section 1557 of the ACA, you can file a complaint with the federal Department of Health and Human Services Office of Civil Rights. For more information, visit How to File a Civil Rights Complaint.
If you have a self-funded health care plan through an employer with at least 15 employees, you can file a discrimination complaint with the federal Equal Employment Opportunity Commission (EEOC). For more information, visit the Discrimination Issue Area.
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