Navigator Guide FAQs of the Week: Marketplace Coverage Issues for LGBTQI+ Individuals

It’s time to sign up for 2024 coverage on the Affordable Care Act’s Marketplaces. This week, the Centers for Medicare & Medicaid Services (CMS) is spotlighting how the Marketplaces can serve LGBTQI+ individuals, a community that has historically faced discriminatory barriers to health insurance and health care. Here are a few frequently asked questions (FAQs) from CHIR’s Navigator Resource Guide about some Marketplace coverage issues that LGBTQI+ individuals may face.

My plan refuses to cover services related to gender transition. Is this allowed?

Coverage of gender transition services varies by insurer and state. The Affordable Care Act prohibits health plans and providers that receive federal financial assistance from discriminating on the basis of sex, which includes discrimination on the basis of gender and gender identity (the regulation implementing this provision is currently being revised, but the law’s protections are still in effect). This generally means that Marketplace plans cannot categorically refuse to provide you treatment based on your gender identity and must cover medically necessary services as long as those services are covered for other people on your plan. For instance, a Marketplace plan may not deny coverage for preventive screenings (e.g., mammograms, pap smears, and prostate exams), mental health services, or surgical procedures related to gender transition based on a person’s sex assigned at birth. If you believe you are being discriminated against by your health plan when seeking gender-affirming care, you should first seek to appeal any adverse benefit decisions. You can also file a complaint with the U.S. Department of Health & Human Services’ Office of Civil Rights or with your state Department of Insurance. For assistance determining the right course of action for you, there are several legal organizations you can contact. For more information on state-specific requirements with regard to coverage of transgender and transition-related services, see Out2Enroll’s Trans Insurance Guides.

I am taking pre-exposure prophylaxis (PrEP) to prevent HIV, but my insurance plan will not cover the medication my doctor prescribed without cost sharing. Is this allowed?

It depends. PrEP is a recommended preventive service, and plans that comply with the Affordable Care Act must cover it without cost sharing. However, federal guidance allows plans to require use of generic or preferred brand drugs for PrEP unless there is a medical reason to use the non-preferred brand name drug. In that case, you are entitled to the medically appropriate non-preferred brand name drug without cost sharing. If you think your medication was denied inappropriately, you can appeal this decision starting with the internal appeals procedure your insurer must provide you. (CMS, Affordable Care Act Implementation FAQ – Part 47, July 19 2021).

I am interested in making sure my plan includes a provider who is culturally competent. Do provider networks list the race/ethnicity of the provider or their experience with certain communities?

Provider directories do not have to include information about the race/ethnicity of the provider or specific expertise in working with particular communities. Some provider networks, however, voluntarily include this information. If you are interested in finding providers in your network who are from or who have experience working with certain communities, looking to national and state provider networks hosted by professional medical associations may be helpful (for example, Black Doctor.org, and Trans Health).

In most states, consumers have until December 15 to sign up for Marketplace coverage that begins on January 1. Check out the Navigator Resource Guide for additional FAQs, resources for diverse communities, state-specific information, and more.