Facial feminization surgery and voice lessons for transgender people are now covered by the largest health insurance provider in the state. On July 1, Blue Cross and Blue Shield of North Carolina updated its policy to recognize these gender-affirming health care procedures as medically necessary.
The national nonprofit Transgender Legal Defense & Education Fund led advocacy for the change on behalf of two employers, Equality North Carolina and the LGBTQ Center of Durham, as well as two transgender women who were denied pre-authorization for services by Blue Cross NC. One of the women, Kathryn Vandegrift, lived in Asheville until June.
Blue Cross NC’s updated policy is welcome news to transgender North Carolinans who are among the insurer’s 357,000 members in Western North Carolina, as well as health care providers who serve the LGBTQ population. Although the U.S. census does not ask about gender identity, a 2016 report by The Williams Institute at the UCLA School of Law estimated that 0.6% of North Carolina’s population identifies as transgender.
“It’s a human right that people have access to health care, so insurance companies should not discriminate against trans people,” says Jennifer Abbott, a physician with the TRANSition Assistance Program at Western North Carolina Community Health Services, an Asheville community health clinic. Facial surgery and voice therapy are “essential care for people who are trans,” she says.
A medical necessity
Blue Cross NC developed its first gender affirmation surgery and hormone therapy policy, which addresses people diagnosed with gender dysphoria, in 2011.
Gender dysphoria in adolescents and adults is defined as “a marked incongruence between one’s experienced/expressed gender and their assigned gender” by the American Psychiatric Association. Some gender-dysphoric individuals undergo medical procedures to align their body with their gender identity.
Blue Cross NC’s initial policy recognized hormone therapy, breast augmentation surgery and mastectomy as medically necessary procedures under some benefit plans. It did not give the same status to facial feminization surgery or voice lessons, and members who submitted pre-service authorizations for these procedures were routinely denied.
That’s what happened when Vandegrift applied for pre-service authorization for facial feminization surgery last year. In April 2020, she had started a new job in Asheville as a field organizer for the N.C. Democratic Party. The full-time position came with the option of health insurance benefits through Blue Cross NC, but she soon learned that her policy would not cover the procedure.
“The word I use to describe this denial of my self-care is ‘devastating,’” she says. “Seeing that and finding out this is how they regarded our health care, it made the day very unpleasant.”
Vandegrift’s experience is not uncommon. According to North Carolina data from the 2015 U.S. Transgender Survey conducted by the National Center for Transgender Equality, 21% of respondents reported a problem with their insurance in the past year related to being transgender, such as denial of coverage for care relating to gender transition.
Both national and global health care organizations, however, hold that such care is critical. The American Medical Association recognizes gender-affirming care as medically necessary and evidence-based. And the World Professional Association for Transgender Health wrote in a 2016 statement that such medical procedures “are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.”
WPATH’s statement continued that, in some cases, gender-affirming surgery can be the only effective treatment for gender dysphoria — and therefore, can be “lifesaving.” Of respondents to the 2015 NCTE survey, 40% had attempted suicide in their lifetime, roughly nine times over the U.S. rate of 4.6%.
Vandegrift received Blue Cross NC’s denial in July 2020; she appealed the denial shortly thereafter and received the insurer’s denial of that appeal in September 2020.
During this time, Vandegrift was referred to Noah Lewis, the trans health project director at TLDEF, who has led the nonprofit’s initiative advocacy for health insurance policy changes since early 2020. Along with pro bono lawyers and law students from the Health Justice Clinic at Duke University School of Law, TLDEF “approached Blue Cross NC to resolve this in a collaborative process,” Lewis says. Vandegrift also filed a civil rights complaint with the insurance company.
Lewis says the insurer was initially unreceptive to expanding its covered services. “But as we continued to provide them with legal and medical information, they did a number of rounds of review of their policy” and made some incremental changes, he continues. “Ultimately, their review committee made the bigger change of covering facial surgeries and voice therapy.”
When asked for clarification on how procedures are reviewed, Blue Cross NC spokesperson Jami Sowers wrote in a statement, “As part of an ongoing review process that includes practicing physicians both employed by and independent of Blue Cross NC, Blue Cross NC has made updates to its gender affirmation surgery and hormone therapy policy.“
Vandegrift learned of the policy change when she received pre-service authorization for facial feminization surgery in May. In the days leading up to the procedure on July 29, she was disbelieving. “My immediate reaction was to worry that it looked too good to be true and that it wouldn’t actually happen in some way,” she says.
Although Vandegrift is glad to have gotten the care she needed, she calls the past year “a long and an emotionally draining process.” She still struggles with the insurance company’s initial rejection that her surgery was a necessity.
“It gets under your skin and in a way makes you doubt yourself,” she explains. “It makes you doubt your own existence of who you are, and that’s when the feelings become really bad.”
A continuing need
More can be done in North Carolina to promote health care access for transgender patients, says Abbott of WNCCHS. For example, insurers could lift prior authorization requirements for some medications, especially injectable hormones. This would prevent a prescription from being denied at a pharmacy without an additional form from the prescribing physician verifying that the medication is required. Several insurance providers, including Blue Cross NC, have required her to issue prior authorization for this care, she says.
But the WNC medical community is improving at providing gender-affirming care, Abbott says. Best practices include using the correct name and pronouns while talking to patients, providing mammograms when needed and prescribing affirming hormones.
WNC offers more affirming health care providers today than when Abbott began seeing transgender patients at WNCCHS 14 years ago, she says. But other areas have gaps in coverage. The clinic’s TRANSition Assistance Program serves 400 to 500 transgender patients, some of whom travel from as far as Gastonia — over 100 miles to the southeast.
Gender-affirming surgeries are on the rise nationwide. Data from the American Society of Plastic Surgeons shows that from 2019 to 2020, facial surgeries for trans female patients rose 14%, from 964 to 1,102. Sex reassignment surgeries for transgender women rose during that time as well.
But surgeries could be more accessible in North Carolina. Abbott’s one patient who sought facial feminization surgery went out of state for the procedure. The UNC Chapel Hill School of Medicine provides numerous gender affirming services out of its urology department; Abbott has referred a patient there for top surgery. Abbott hopes that reconstructive surgeons will get more training on how to address the needs of transgender patients in the state. “There are still barriers that need to come down so trans people can access everything they need,” she says.