Measure would bar insurance from denying gender-affirming procedures

Sy Bernabei, a trans and gender-nonconforming person who works with the nonprofit Gender Justice Nevada, paid $9,000 out of pocket for recent gender-affirming surgery to avoid dealing with private insurance.

Albi Smedley, a non-binary trans person who is employed by Clark County School District, pays $300 out-of-pocket for hormones and is still excluded from having gender-affirming surgeries covered by insurance.

“When something so fundamental and necessary as health care for basic needs is not covered by your trusted employer, it’s an entirely demoralizing experience,” Smedley said. “I can’t stress enough the dehumanizing effect of seeking care for fundamental health needs and being unsupported by your employer, your insurance or your government.”

While sharing their struggles to access health care and get insurance to cover medically necessary procedures, many trans and gender-nonconforming people pressed lawmakers Friday during a Senate Committee on Commerce and Labor hearing to enact a law protecting them from insurance discrimination. 

Senate Bill 139 would require certain health insurance policies, including Medicaid, to cover “the treatment of conditions relating to gender dysphoria, gender incongruence and other disorders of sexual development.”

Procedures that affirm a person’s gender could range from “top surgery,” which includes breast reduction or removal, to voice therapy, depending on what a health care provider has deemed medically necessary for that person. 

“I want folks to know, this is not something that trans and gender-nonconforming people do lightly. It is an act of bravery to begin socially and medically transitioning,” Bernabei said. “I’ve worked over 20 years in this community and I’ve seen depression, self-harm and suicide when gender-affirming procedures and hormone therapy are not covered by insurance. Making health care not as accessible increases those things.” 

While being praised by civil rights and LGBTQ groups, the legislation also received support from SilverSummit Health Plan, a state-based insurance plan.

The only opposition was from the Lyon County comptroller, who worried about the financial burden the legislation might place on smaller insurance plans. 

The Nevada Association of Health Plans testified in “neutral,” saying it was working with the bill’s sponsors, Clark County Democratic state Sens. Melanie Scheible and Dallas Harris, to clarify some of the language. 

If passed, Brooke Maylath, who presented the bill alongside Scheible, said Nevada would be “the first state to be able to have something this broadly mandated.”

There is a long history of discrimination against trans individuals seeking health coverage.

“Beginning in the 1980s, it was common for health insurance plans to have exclusions for any coverage for medical treatment to change or alter sex,” Maylath said. 

In 2015 the Affordable Care Act prohibited insurance companies from refusing to cover procedures for transgender people. 

The Nevada Division of Insurance issued a bulletin shortly after to affirm its commitment to ensure procedures couldn’t be denied because of gender identity or expression. 

Maylath said those laws and policies haven’t stopped trans people from being denied coverage nor have they stopped the bias that has led to some of those denials. 

“During 2020, I personally counseled an individual through multiple preauthorization denials from a third party administrator contracted with their employer’s self-funded plan.” Maylath said.

Even though the person’s employer-provided plan expanded to include coverage for their procedure, a mastectomy, the person kept receiving denials from the insurance company. It took eight months of fighting to finally get reimbursed.

Many supporters argued not everyone has the resources or time to engage in bureaucratic back and forth to get medically affirming procedures covered.  

State Sen. Keith Pickard questioned whether there was a need for the legislation if there was already a policy. 

“What people are experiencing in practice is inconsistent with the decision and ruling by the Department of Business and Industry,” Scheible said. “I think that I’m not the first legislator to encounter this problem and come up with a legislative solution. That’s what this bill does. It puts into law what the Division of Insurance has already said is their interpretation of the law.”

Clark County submitted a fiscal note for the bill saying if Clark County’s Self-Funded Group Insurance expanded coverage for conditions related to gender dysphoria “assuming two reassignment surgeries per year, or one per 10,000 members,” the cost would be $1.5 million over two years.

No one from Clark County testified at the hearing. 

Maylath pushed back on fiscal estimates and argued surgeries, like a mastectomy, are already covered for cisgender women. 

Denying trans people coverage could result in costly litigation, something that has happened across the country.

“These exclusions have been challenged throughout the country and plaintiffs have won costing the insurance plans hundreds of thousands of dollars in penalties above the cost of actually paying for the procedure,” Maylath said. “In one sense, this bill is in insurance companies best interest.”