Navigating Health Benefits Equity for LGBTQ+ Members
4 minute read•Navigation Insider
Societal shifts, employee expectations and potential legal ramifications are spurring employers to examine — as never before — diversity, equity and inclusion within their workplace cultures, hiring practices and benefits.
For employees and dependents who identify as lesbian, gay, bisexual, transgender and questioning/queer (LGBTQ+), most employers’ health plans are playing catch-up to recent historic gains elsewhere in society — from legalization of same-sex marriage to antidiscrimination employment laws.
Quantum Health provides healthcare navigation and care coordination for more than 2.1 million health plan members. That uniquely positions us to help HR teams and benefits consultants identify, and find solutions to, any benefits gaps and access challenges members experience. Following are three areas where we’re helping clients make progress toward greater benefits equity for LGBTQ+ members.
When you apply an equity lens to health plan language regarding infertility, those benefits might not be helpful to LGBTQ+ members interested in forming a family. Why? Because many plans require a diagnosis of infertility — a medical condition — before they provide coverage for fertility treatments such as intrauterine insemination (IUI) or in-vitro fertilization (IVF). The traditional assumption underlying those benefits is that a different-sex couple has tried and failed to become pregnant over a specified timeframe. However, the same proof-of-infertility requirement would apply to a lesbian couple whose repeated attempts at pregnancy via IUI have failed.
But for most LGBTQ+ members, infertility isn’t the question. Fertility is. They want to have a child, and are physically capable of contributing to a successful pregnancy, but their health benefits don’t include fertility benefits without the proof of infertility.
In this instance, rewriting the health plan isn’t the answer to greater equality because fertility isn’t a medical condition. Instead, employers increasingly offer expanded “family-forming benefits” for all members. These might include support for adoption and surrogacy, or a fertility point solution that offers egg preservation, specialized conception care, in vitro conception, and other services. Quantum Health knows of one employer that is considering forming a foundation to provide members with financial support for family-forming services.
Coverage for fertility and family-forming benefits such as IUI, IVF and surrogacy will almost certainly become more common as employers recognize the equity issues and strive to meet employees’ expectations. A Society for Human Resource Management survey found that more than two-thirds of millennials are looking to employers for fertility benefits. Meanwhile, a 2022 Business Group on Health (BGH) survey found that the number of large employers that offer fertility benefits to all types of families will more than double soon, from 34% in 2021 to 71% by 2024.
Many employers are taking steps to ensure transgender employees receive the care and support they need to fully realize their identity. Last year, Quantum Health collaborated with several clients as they evolved their health plan language to cover gender affirmation surgery.
National trends confirm what we’re seeing. In its 2022 survey, BGH found that 75% of large employers expected to offer or expand transgender healthcare benefits in 2021, and another 10% planned to do so by 2024. Some will provide coverage for the first time. Others will expand eligibility or lifetime maximum benefits for affirmation surgery and other transition procedures.
Just as with fertility benefits, looking at gender affirmation through an equity lens can lead to rethinking a health plan’s traditional language and coverage limits. Two examples? “Gender dysphoria” and “medically necessary.”
Gender affirmation-related services often are only covered after a member is diagnosed with “gender dysphoria.” The American Psychiatric Association defines the term as “clinically significant distress or impairment related to a strong desire to be of another gender.” The organization also notes that not all gender-diverse people experience dysphoria. In fact, many feel at ease with their identity as they pursue treatment options to affirm it. Quantum Health offers insights from our clinical team, and from our engagements with LGBTQ+ members, as clients decide whether a dysphoria diagnosis should remain a requirement in their health plans.
Similarly, traditional health plan language often limits coverage to treatments considered “medically necessary.” Until relatively recently, gender affirmation surgery was deemed elective. However, now the American Medical Association, American Psychological Association and American Psychiatric Association all consider mental health counseling, as well as gender-affirming hormone therapy and surgeries, medically necessary. While leading medical associations agree on the medical necessity of genital surgery and mastectomy (so-called “bottom and top surgeries”), opinions still vary whether procedures such as breast augmentation, liposuction or facial feminization are necessary or elective.
All of this has HR leaders and benefits advisors rethinking “medically necessary” as it relates to transgender benefits, with some moving toward a more nuanced standard in their plans. Quantum Health’s experience supporting members on gender-affirmation journeys indicates that providing coverage for certain elective procedures typically serves to support their transition and boost their physical and emotional well-being.
Unfortunately, LGBTQ+ people are among the most likely to experience discrimination when accessing healthcare. Historically, health professions treated being LGBTQ+ as a pathology. A 2017 Center for American Progress survey found that LGBTQ+ people experience discrimination in healthcare settings, it discourages them from seeking care, and they may have trouble finding alternative services if turned away.
Discrimination does not have to mean outright hostility. Providers sometimes simply default to assuming each patient is heterosexual or “cisgender” (a person whose sense of personal identity and gender corresponds with their birth sex). When they demonstrate those biases in their approach to gathering health history and asking diagnostic questions, the care setting can become an uncomfortable and even painful place for an LGBTQ+ member.
At Quantum Health, our Care Coordinators are trained to help all members find high-quality, cost-effective in-network providers, centers of excellence and specialty point solutions within their employers’ health plans. They also have access to databases such as the World Professional Association for Transgender Health and the Gay and Lesbian Medical Association provider directory, which we research regularly on behalf of LGBTQ+ members. Whenever possible, we guide LGBTQ+ members not only to providers who are welcoming and open-minded, but who have special training and expertise in LGBTQ+ care.
One of our Personal Care Guide nurses recalls working with an LGBTQ+ member who had Crohn’s disease and was relocating to Florida. He felt anxious about finding appropriate and inclusive care. Our Care Coordinators were proactive in finding him a home healthcare agency and a primary physician that were welcoming and attentive. With all the changes and stressors involved in the move, the member appreciated our team’s support in helping to facilitate his care.
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