“It is the policy of UPMC Insurance Services Division to cover gender affirming (gender confirmation) surgery when medically necessary and covered under the member’s specific benefit plan,” UPMC’s Policy and Procedures Manual for gender affirming surgery reads. As of December 2021, covered surgeries now include FFS.
Most health insurers nationwide, including Highmark and Medicare, do not cover FFS for trans women, categorizing the procedures as “cosmetic.”
Advocates say that, especially when it comes to transgender people pursuing surgical transition, the line between cosmetic and medically necessary is not as clear as most insurers think it is. FFS, which can range up to $30,000-50,000 without insurance, has been reported to significantly affect trans patients’ mental health and social welfare and is “arguably the most commonly denied surgery,” according to a May 2021 study from The University of California.
In Pittsburgh, local trans-led nonprofit TransYOUniting is celebrating the announcement.
“We are grateful that UPMC is working to provide more culturally competent care and support for the transgender population by supporting medically necessary FFS and we encourage all insurance providers to do the same,” TransYOUniting says in a statement to Pittsburgh City Paper. “FFS is life-saving care that has been denied to so many of our people, so this is the right step in the right direction. We hope their insurance coverage policy also means they are providing culturally competent health care and employment opportunities for our community members as well,” the statement reads.
Even with this expansion of coverage, like with other gender-affirming surgeries, there are still criteria one must meet in order to get FFS covered.
In order for UPMC to consider FFS medically necessary, they require, “a persistent, well-documented diagnosis of gender dysphoria,” including “the desire to live and be accepted as a person whose gender is different than sex assigned at birth,” that causes clinical distress or impairment in “social, occupational, or other important areas of functioning.” Patients must also be at least 18 years old and able to give their informed consent, in addition to receiving one referral from a qualified mental health professional and 12 months of continuous hormone therapy (unless the patient has a medical contraindication or is otherwise unable to take hormones).
“I would like to first say that we are thrilled that UPMC has expanded coverage to include facial feminization surgeries and laser hair removal,” Remy Black, Transgender Patient Navigator at North Side’s Central Outreach Wellness Center, wrote in an email to City Paper. “This policy change will truly change the lives of transgender patients in our network who will be able to access quality care to begin living in a body that is congruent with their gender identity,” she continued.
Black says that COWC “expect[s] some delays and growing pains” as UPMC works to make sure trans patients have access to “competent providers.” She also expressed a need for Pennsylvania to “catch up to the standards of coverage set by New York and California, which have the most expansive Medicaid coverage for transgender patients in the country (including coverage for body contouring, dermal fillers, and many more procedures related to gender confirmation for transgender patients).”
This story has been updated at 2:45 p.m. on Fri., Jan. 28 to add in additional comments from Remy Black of Central Outreach Wellness Center.