Insurers unsure on transgender care

Four months after the state Division of Insurance put health plans on notice that denying medically necessary treatment to transgender people is prohibited sex discrimination, insurers are still grappling with what constitutes medical necessity, and patients are struggling to find doctors who'll treat them.

In a state world-renowned for its medical talent, no Massachusetts physician performs genital gender reassignment surgery, said Elizabeth M. Murphy of the Massachusetts Association of Health Plans.

"We were concerned people were having to go all over the country for this surgery," Dr. Joel Rubenstein of Harvard Pilgrim Health Care said yesterday at a Division of Insurance informational session. "We're hopeful somebody would step up to put together the surgical piece so it could all be in one place."

Under state law, health plans are required to develop evidence-based medical necessity guidelines for such procedures.

"We are determined to ... not exclude treatment for this condition," Rubenstein said.

On the other hand, he said, Harvard Pilgrim does not want to approve procedures such as facial feminization for transgender people if those procedures would be considered merely cosmetic for other people.

"If we cover them for transgender patients, we would be being reverse-discriminatory," said Dr. Robert Nierman, medical director at Tufts Health Plan.

But Ruben Hopwood of Fenway Health said facial feminization is not about wanting a "cuter nose." A transgender person's appearance is more likely to be the difference between getting a job or not getting one, and walking down the street unafraid or being attacked, Hopwood said.

Getting the proper treatment also can save money that might otherwise be spent on treatment for alcohol or substance abuse or depression, said Pam Klein, a nurse at Boston Health Care for the Homeless.

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