TRANSGENDER-AFFIRMING HOSPITAL POLICIES F. Internal Sanctions. Under the Privacy Rule, a covered entity must have in place and apply appropriate sanctions against members of its workforce (i.e., physicians, employees and contractors) who violate the entity’s policies and procedures and the Privacy Rule.62 Hospitals should specify that inappropriate use, disclosure, or request of a transgender patient’s protected health information is both a violation of the hospital’s internal HIPAA policies and procedures and a violation of the Privacy Rule and that such violations will be subject to appropriate disciplinary action.
18 made aware of their right to complain about improper uses or disclosures of their protected health information. Insurance Issues The negative experiences that these model policies aim to eliminate are often compounded by insurance-related practices that create additional barriers to care. To foster a better understanding of the insurance issues faced by transgender patients, this section briefly discusses insurance-related practices that affect access to quality health care.
G. Complaints. The Privacy Rule requires that covered entities must provide a process for individuals to make complaints concerning the entity’s policies and procedures required by the Privacy Rule and its compliance with such policies and procedures.63 A covered entity must document all complaints received and their disposition, if any.64 Hospitals should review their policies to ensure that a proper process is established for documenting and responding to complaints and should ensure that transgender patients are
Leading authorities in the medical and policy communities,65 including the American Medical Association and American Psychiatric Association, have recognized the medical necessity of sex reassignment surgery (SRS)66 and hormone therapy for patients with “gender dysphoria” (formerly classified as “gender identity disorder”).67 As a result, an increasing
62. 45 C.F.R. §164.530(e). 63. 45 C.F.R. §164.530(d)(1). 64. 45 C.F.R. §164.530(d)(2). 65. For a full compilation of professional organizations’ statements in support of access to care for transgender patients, see Lambda Legal, Professional Organization Statements Supporting Transgender People in Health Care (July 2, 2013), http://www.lambdalegal.org/publications/fs_professional-org-statements-supporting-trans-health. See also, e.g., Am. Med. Ass'n H.D., Resolution 122 (A-08): Removing Financial Barriers to Care for Transgender Patients (June 2008), http://www.tgender.net/taw/ama_resolutions. pdf (“Whereas, An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID; and . . . Health experts in GID . . . have rejected the myth that such treatments are ‘cosmetic’ or ‘experimental’ and have recognized that these treatments can provide safe and effective treatment for a serious health condition . . . therefore be it . . . Resolved, That the AMA oppose categorical exclusions of coverage for treatment of gender identity disorder when prescribed by a physician . . . .”); Am. Psychiatric Ass'n, Position Statement on Access to Care for Transgender and Gender Variant Individuals (July 2012), https://www. psychiatry.org/file%20library/about-apa/organization-documents-policies/ policies/position-2012-transgender-gender-variant-access-care.pdf (“[T]he American Psychiatric Association . . . [r]ecognizes that appropriately evaluated transgender . . . individuals can benefit greatly from medical and surgical gender transition treatments . . . [and] supports both public and private health insurance coverage for gender transition treatment.”); Am. Psychiatric Ass'n, Council of Representatives, Transgender, Gender Identity, & Gender Expres-
sion Non-Discrimination (Aug. 2008), http://www.apa.org/about/policy/ transgender.aspx (“APA recognizes the efficacy, benefit and medical necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments”); Am. Med. Ass'n, Resolution 122: Removing Financial Barriers to Care for Transgender Patients (June 2008), http://www.tgender.net/taw/ama_resolutions.pdf (“Resolved, That the AMA support public and private health insurance coverage for treatment of gender identity disorder . . . .”). Note also that numerous federal courts have recognized gender dysphoria as an objectively serious medical condition for Eighth Amendment purposes. See, e.g., Fields v. Smith, 653 F.3d 550 (7th Cir. 2011) (state law that prevented medical personnel from providing hormone therapy to inmates with gender identity disorder was an unconstitutional violation of the Eighth Amendment). Moreover, following a U.S. Tax Court decision, the Internal Revenue Service has agreed with the court’s determination that expenses incurred for hormone therapy and sex reassignment surgery, that are not compensated for by insurance or otherwise, are tax deductible expenses under Section 213 of the Internal Revenue Code. See Internal Revenue Service, Action on Decision: O’Donnabhain v. Commissioner, 134 T.C. 34 (2010) (Nov. 21, 2011), http://www.hrc.org/files/images/pages/ Transgender_IRSagreeswithTaxCourt_2011.pdf. 66. Note that this may also be termed “Gender Reassignment Surgery” and abbreviated GRS. Gender-affirming surgeries include a variety of surgical procedures that may be a part of a person’s gender transition. 67. For a description of the “gender dysphoria” diagnosis as it appears in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), see American Psychiatric Association, Gender Dysphoria (2013), http://www. dsm5.org/Documents/Gender%20Dysphoria%20Fact%20Sheet.pdf.
Exclusions and Denials of Insurance Coverage for Medically Necessary Care for Transgender Patients