See "Benefits for Transgender Employees and Dependents" for our resources on transgender-inclusive health insurance.
When the CEI first began in 2002, 145 of the Fortune 500 companies and thousands of government contractors had implemented partner benefits either independently or as a result of equal benefit ordinances passed by San Francisco and others. At the same time, only two employers were known to offer inclusive health insurance benefits for transgender people.
The HRCF first announced changes to the Corporate Equality Index criteria in 2004 (which went into effect in 2006). When consulting with transgender health insurance and other transgender workplace advocates at the time we knew we needed to do more to break down the very real barriers to transgender-inclusive health insurance that existed. There were several challenges that needed to be faced:
- employers (benefit managers, human resources, etc.) didn’t understand that this discrimination existed and how they could change it
- there are several types of treatment that insurance discrimination affected and health insurance wasn’t the only barrier – for example, employers have disability insurance for the cases when a worker takes paid short-term leave for medical reasons that wasn’t necessarily available for transgender employees
- inclusive insurance was not widely available, and insurers told employers it wasn’t possible to get it covered (or, if it could be covered, it would be prohibitively expensive).
In 2004 we started asking questions on the survey that we hoped would drive the point home: if an employer’s insurance provided coverage for any of these types of treatments, generally, would the insurance cover these treatments for medically necessary transgender-specific care?
It turned out that these questions by themselves still didn’t always get the point across –employers weren’t as familiar with the fine print of their contract language as we had thought. As we reviewed surveys, we would flag answers to questions that looked inconsistent. “Well, of course, we cover any medically necessary treatment, but we don’t cover sex reassignment.” Well, which is it, then? The question came down to, in many ways, “who says it’s medically necessary?” And the WPATH Standards of Care (then, the Harry Benjamin International Gender Dysphoria Association’s Standards of Care) weren’t being recognized in the corporate community as authoritative in determining what was medically necessary.
In these cases, it turns out there probably wasn’t one correct answer for whether the employer provided inclusive insurance or not because the transgender exclusion language may have been ambiguous or silent on particular categories of treatment – some transgender people may have been able to get some treatments covered, particularly if the employer helped intervene with the insurer, but more often than not coverage was probably denied.
When the time came to implement these criteria in 2006, we ultimately settled on requiring just one of the five categories of coverage, knowing that this meant employers could get full credit for providing mental health counseling or short-term leave alone. There was still too much education that had to be done with employers and improvements that had to be made in the survey if we wanted to accurately rate employers on transgender-inclusive insurance. We took each survey year as an opportunity to refine the questions, enhance our educational resources and information on transgender-inclusive health insurance and work with businesses one-on-one, each year, to ensure that they knew what questions to ask their insurers to answer the survey accurately.
In the Corporate Equality Index report released September 2007 (CEI 2008), more than seventy employers had indicated that their insurance covered all five categories of treatment we surveyed. However, despite having continually refined the questions we asked in the survey, as well as the supporting educational information we provided to participants on our website and in the survey help and FAQ’s, we still heard back from transgender employees or employees with transgender dependents that coverage wasn’t available at some of the employers that had indicated as much. And some transgender employees and dependents told us that they were able to get some treatments covered, but that coverage was denied for other treatments, because they were considered “cosmetic,” despite these treatments being significantly important to some transitioning people’s ability to live without harassment and threats for being transgender.
Iin the most recent survey (the 2009 Corporate Equality Index survey, due June 30, 2008), we took a new approach for the questions. We still asked about the five general categories of benefits, but added questions qualifying what those benefits looked like and, most importantly, required businesses to submit some form of documentation. This marked a significant departure because employers are loathe to hand over proprietary benefits information to us. Armed with this documentation, the HRC Foundation felt confident enough in the data to begin reporting the additional information of which employers provide an insurance option that fully includes transgender-specific care or treatment.
As the survey deadline neared in June of 2008, two key developments occurred. The American Medical Association issued a statement that affirmed the medical necessity of treatment as defined by the World Professional Association for Transgender Health, and WPATH issued a statement reaffirming the medical necessity of treatment.
In the 2009 Corporate Equality Index report, released September 2008, nearly fifty employers had adequately demonstrated that their insurance covered all five categories of treatment we surveyed for transgender employees and dependents. The drop in the number of employers that provide these categories of treatment should not be interpreted as employers dropping coverage, but rather a more accurate representation of the employers that do -- in fact -- provide these benefits. These 49 employers were individually highlighted in the CEI report as leaders that will help establish inclusive benefits in states or insurance providers where inclusive health insurance is still not available.
Given the years working with employers on transgender-inclusive insurance, the success of employers that have already demonstrated broadly inclusive coverage, the key support of the American Medical Association and clarification from WPATH, we feel prepared to provide employers with concrete requirements for inclusive insurance moving forward.
Essentially, we will require that at least one insurance option available to all employees must have a contract where:
- transgender exclusions must be removed or substantially modified to ensure coverage for transgender-specific treatment
- either directly in the contract or in clinical guidelines referenced by the contract, the insurance plan must acknowledge the WPATH Standards of Care to determine what treatment will be considered medically necessary
We fully expect that some of the largest employers — especially those that do not purchase health insurance but rather “self-insure” by funding their insurance plan — and those employers that currently work with insurance providers that already provide inclusive insurance to some of their customers, will be able to implement this change sooner than others. Other employers will need education from their employees and their peer companies and will have to enter negotiations with insurance providers to make this change happen.
Because benefits plans typically change only once per year, because many employers currently work with insurance providers that do not provide inclusive insurance to any of their employers, and because the CEI must be achievable in order to motivate employers to participate in the first place, these changes will not need to be effective until open enrollment of 2012 to receive credit in the 2012 CEI. In reality, it will take even the best intentioned businesses time to institute fully inclusive health insurance coverage for their transgender employees. HRC will continue to provide the resources and guidance that employers need to meet those challenges and that transgender employees and their allies need to effectively advocate for them.
Through the intensive educational and consultative efforts to address health care and insurance disparities for the transgender population and their families, including: outreach to leading health insurance companies direct consultation with both fully and self-insured employers to modify their health care plans and collection and dissemination of cost and utilization data from leading businesses, the HRCF led an increase in the number of major U.S. employers affording transgender-inclusive health care coverage, from 0 in 2002 to 49 in the 2009 CEI to 278 in the 2013 CEI to 336 in 2014.
This year in the 2015 CEI, an impressive group of 418 CEI participants now have transgender-inclusive health care coverage. These benefits are critical for the health and well-being of individual transgender people. According to businesses reporting to the HRCF, making these benefits accessible comes at an overall negligible cost to the employers’ overall health insurance plans. This holds true across industries.