Prior to 2014 and the implementation of the Affordable Care Act (ACA), if you are lesbian, gay, bisexual, or transgender (LGBT), you may have found it difficult to access affordable and comprehensive health insurance. You may have even been denied coverage altogether due to a pre-existing medical condition.
But did you know that the new law establishes significant protections for LGBT individuals, making health insurance more accessible than ever before? The Affordable Care Act …
Prohibits Discrimination Based on Sexual Orientation or Gender Identity. You cannot be discriminated against by the marketplace, health insurance companies, health plans, agents and navigators, and any health plan or organization (hospital, doctor, clinic, etc.) that receives federal funding.
Eliminates Pre-Existing Conditions. Under the ACA, all health plans are guaranteed issue. This means you cannot be denied health insurance for any reason — including pre-existing medical conditions like HIV, mental or behavioral health conditions, diagnosis of gender identity disorder/gender dysphoria.
Prohibits Charging Higher Premiums for Pre-Existing Conditions. You cannot be charged a higher premium based on your health status.
Provides Income-Based Financial Assistance. If you meet certain income requirements, the government will give you a premium subsidy to help you pay for coverage.
Grants Rights to Legally Married Same-Sex Spouses. If you were married in a state where same-sex marriage is legal, AND you file a joint federal tax return, you can apply jointly for a subsidy through the marketplace. This is true no matter where you live today.
Offers Family or Spousal Coverage to Legally Married Same-Sex Spouses. Starting January 1, 2015, if an insurance plan offers family or spousal coverage in the first place, it must offer that coverage to all married couples — regardless of sexual orientation — as long as you were married in a state or country where same-sex marriage is legal. This is true no matter where you live today, where the insurance company is located, and where the plan is sold.
Requires Coverage for Care Related to Gender Transition for Transgender People. Any care that is covered on the plan must be covered for you if you are transgender. For example, things like hormone replacement therapy, mental health counseling, and gender-specific care (e.g., mammograms, Pap tests, prostate exams) must be covered for ALL policyholders, regardless of gender identity or gender expression. The same holds true for surgeries like hysterectomy or mastectomy — if it’s covered under the plan, then it’s covered for you if you are transgender.
Requires Coverage for Essential Health Benefits. This coverage — including prescriptions, mental health services, preventive services, etc. — must be offered to all policyholders.
Guarantees a Review Process for Any Claim that is Denied. Both an internal and external review process will allow you to appeal any decision.
Protects the Privacy of Your Sensitive Information. The ACA, along with the Health Information Portability and Accountability Act (HIPAA), protects you from improper disclosure of your medical or other sensitive information without your consent.
Things to Consider if You Are LGBT
When looking for health insurance, here are a few tips:
Be sure you fully understand the terms of coverage included with any plan you are considering. Be aware of any exclusions that may impact you, particularly if you are transgender. If you are already enrolled in a plan, you have the right to appeal any denial of a claim.
Be sure you fully understand a plan’s drug formulary. Be sure any medications you take on a regular basis are covered under your plan.
Be sure your preferred doctor or other medical provider is included in your plan’s network. The Gay and Lesbian Medical Association (GLMA) can be a resource for finding LGBT-friendly providers.
When applying for coverage on the marketplace, when it asks if you are married, as long as you are legally married, and you and your spouse plan to file a joint tax return, select “yes”.
When applying for coverage — either through the marketplace or directly with a carrier — use the name and sex that is on the majority of your ID documents such as your driver’s license or Social Security card.
Virginia Medical Plans Can Help
If you live in Virginia, Maryland, or the District of Columbia, we can help you find the best coverage to meet your needs.
Please call our office at 703-707-8270 to speak with someone today!
But please keep in mind, outside the dates of open enrollment you can only secure individual or family coverage if you have a qualifying event.