research

Executive Summary

More than a million lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) individuals receive health care coverage from the Medicaid program, a state and federal partnership providing health coverage and access to care to 80 million individuals with low incomes in the United States. As the national health care discussion focuses increasingly on health equity and health care stakeholders work toward eradicating health disparities, this report explores the current status of health equity efforts in Medicaid for LGBTQI+ individuals.

While LGBTQI+ communities have made substantial strides in recent years toward improving access to health coverage and care, a great deal of work remains to be done. Medicaid health plans are partnering with providers, community-based organizations, and other stakeholders to change internal and public policies, improve coverage and benefits, and build competency throughout their operations to better serve LGBTQI+ people. Medicaid health plans have established numerous and diverse effort to improve the health care that LGBTQ+ members receive.

The work to ensure that Federal and state health care policies offer protections from discrimination against LGBTQ+ people is ongoing, and efforts to center health equity for LGBTQI+ Medicaid enrollees is still in progress. By committing to improving the health of LGBTQI+ individuals, Medicaid health plans are making progress toward that end.

 

Introduction

LGBTQI+ communities in the United States

Lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) communities are diverse, encompassing all races and ethnicities, religions, ages, and social classes, and have experienced increased visibility and acceptance in recent decades by non-LGBTQ+ society.[1] According to a 2021 Gallup poll, an estimated 5.6 percent of American adults identified as LGBT, including an estimated 0.7 percent of adults who are transgender.[2] This represents a 1.1 percentage point increase since Gallup last measured LGBT identification status in 2017; growth is largely due to members of younger generations identifying as other than heterosexual more often than older generations. An estimated 1.7 of the population born with intersex traits are not included in this estimate.[3]

Despite significant recent progress by LGBTQI+ communities toward full civil rights, people in LGBTQI+ communities continue to experience many social and societal inequities. Research has found this to be driven by persistent social stigma, systemic and individual-level discrimination across all areas of life, denial of basic human and civil rights, and minority stress.[4],[5] While LGBTQI+ people have the same potential for health, well-being, and success are other individuals, research demonstrates that people who identify as LGBTQ+ nevertheless have higher rates of poverty, food insecurity, unemployment, and homelessness than non-LGBTQ+ people.[6],[7],[8],[9],[10],[11] The high percentage of LGBTQI+ individuals and families with low incomes underscores the importance of federal programs such as Medicaid for their health and well-being.

LGBTQI+ communities have made significant progress in recent years through increasing public visibility, understanding, and acceptance; inclusion and equity efforts by health systems, employers, and other institutions; and a patchwork of public policy advances through legislation, regulation, and the courts. For example, more than twenty states and hundreds of localities have passed broad and expressly LGBTQI+ inclusive nondiscrimination laws. Rulings by the US Supreme Court ensured federal recognition of same-sex marriages in 2013 and nationwide marriage equality in 2015.[12],[13],[14] Bostock v. Clayton County, decided by the Supreme Court in 2020, determined that the plain meaning of “because of sex” in Title VII included discrimination based on sexual orientation gender identity.[15] In conjunction with Medicaid expansion and Section 1557 nondiscrimination policies enacted as part of the Patient Protection and Affordable Care Act (ACA), these changes have allowed for considerable gains in health care coverage and access to care for LGBTQI+ people. However, due to ongoing litigation, regulatory changes, and a lack of explicit and comprehensive nondiscrimination protections at the national level, uncertainties and barriers remain for many LGBTQI+ individuals and families.

 

Health and Health Care, Discrimination, and Disparities

As the health care system evolves to address social drivers of health, recognizing the unique social and systemic obstacles encountered by LGBTQI+ communities is important. A recent consensus study by the National Academies of Sciences, Engineering, and Mathematics (NASEM) found that “sexual and gender diverse populations experience numerous disparities in physical and mental health” that “are driven by social forces, such as stigma, prejudice, and discrimination.”[16] Social inequality is inextricably linked to poorer health outcomes, and despite advancements in recent years, ongoing discrimination against LGBTQI+ communities in the health care setting and society at large means that LGBTQI+ individuals continue to experience barriers to good health. Recent political action threatens to bolster these barriers; for example, in 2021 the state of Arkansas enacted a law banning gender-affirming surgery for transgender people under the age of 18, with or without parental consent.[17]

Beyond public policy, LGBTQI+ communities face substantial discrimination and inequities in many areas of life. Bullying in schools, discrimination and harassment in the workplace, and intolerance in public spaces, plus inadequate access to timely, affordable, and high-quality health care, result in deep disparities between the health status of LGBTQI+ individuals and non-LGBTQI+ people.[18],[19]

LGBT status is associated with increased risk for and earlier onset of multiple comorbidities, such as asthma, allergies, osteoarthritis, and gastrointestinal disease.[20] In addition, the high prevalence of HIV among men who have sex with men (MSM) is well-documented; MSM account for an estimated 61 percent of all HIV cases in the United States, and while significant advancements have been made in research and treatment of HIV, infections continue to disproportionally impact sexual minority men, especially among people of color.[21],[22] Access to preventative medication such as pre-exposure prophylaxis, or PrEP, appears inadequate for some populations disproportionately impacted by HIV/AIDS.[23] Sexual minority men also have high rates of other sexually transmitted infections (STI) as well as human papilloma virus, anal cancers, cardiovascular disease, and incontinence.[24],[25],[26],[27]Sexual minority women are at a high risk of obesity, urinary tract infections, asthma, breast and cervical cancers, and cardiovascular disease.[28],[29],[30],[31],[32] Lesbian and bisexual women are also less likely to receive life-saving cancer screenings.[33],[34] Of particular concern for LGBTQI+ communities, then, increasing usage of screenings and other preventative care, access to primary care providers, and continuity of care.

LGBT individuals are also at higher risk for behavioral health problems, including psychiatric disorders, substance use disorders, violence and victimization, and suicidal ideation.[35],[36],[37],[38],[39] Studies have found that LGBTQI+ individuals are 2.5 times more likely to experience depression, anxiety, or substance misuse than the non-LGBTQ+ population. These communities also report higher rates of alcohol and tobacco use.[40],[41],[42] More research is needed on the causes of these disparities, but longstanding discrimination against and victimization of LGBT individuals are likely major factors: LGBTQI+ people are much more likely to have experienced sexual or other violence, with one study finding that 30 percent report being physically threatened or attacked and another finding that three out of four bisexual individuals reported some form of sexual abuse.[43], [44] These numbers likely contribute to the high incidence of mental and physical health problems in LGBTQI+ communities.

Transgender people of all genders face pronounced disparities in both physical and behavioral health. For example, transgender people report experiencing extremely high rates of physical, mental, and sexual abuse, and are especially at risk for behavioral health issues and a lower sense of well-being. [45] Transgender individuals are much less likely to report their health as “good” compared to the general population and report a higher incidence of mental health problems. One national study found that 41 percent of transgender adults had attempted suicide.[46] Rates of HIV and other STIs are also higher among transgender individuals. A recent CDC report found HIV prevalence in seven US cities to be 42 percent for all transgender people, and 62 percent for Black transgender women.[47] These disparities are driven in part by discrimination from the health care system, and by care delayed or avoided out of fear of discrimination: up to 19 percent of transgender patients have been refused medical care due to gender identity or expression.[48] Fear of refusal by providers is a preventable problem that could be alleviated by improved competency among health care providers, institutions, and health plans.

Addressing these disparities will require significant and systemic change by the health care system, including by health care providers. Fewer than half of U.S. medical schools and other health schools include any curricula based on cultural competency specific to LGBTQI+ health needs, and schools with these programs devote a median of just five hours to training.[49],[50],[51] The Association of American Medical Colleges (AAMC) issued recommendations in 2014 for an increase in curricula devoted to LGBTQI+ competency, which may contribute to an increase in medical school training programs in coming years.[52] This recommendation urges medical schools to include training related to clinical scenarios, patient care, professionalism, effective and culturally competent communication, and interprofessional collaboration. Such training does not go unnoticed by patients – one report noted that medical students with experience working with LGBT patients tended to perform more comprehensive medical evaluations and had better clinical interactions.[53] The National LGBTQIA+ Health Education Center, started with a federal grant in 2011, also serves as a source of training and technical assistance for providers across the country.[54]

Several hospitals – including Faulkner Hospital in Boston – have instituted nondiscrimination policies based on sex, sexual orientation, and gender identity and expression.[55],[56] Additionally, the American Medical Association, American Medical Student Association, and American Academy of Pediatrics have all released statements opposing discrimination related to sexual orientation and gender identity or expression. Representing hundreds of thousands of providers, these associations can exert powerful influence over the way health care is delivered.[57],[58],[59] In addition, some major hospitals—including Lurie Children’s Hospital in Chicago and Boston Children’s Hospital—have committed to ending early surgeries on intersex children before they are old enough to participate in decision-making, in accord with a recommendation from the American Academy of Family Physicians.[60],[61]

These efforts, of course, are just the beginning to address inequities in care for LGBTQI+ individuals. A well-documented lack of research and population data surrounding LGBTQI+ health contributes to the inadequate understanding of how to address their needs.[62],[63] The NASEM consensus study recommends that health care providers and government agencies “consider adding measures of sexual orientation, gender identity, and intersex status to all data collection efforts and instruments, such as population-based surveys, administrative records, clinical records, and forms used to collect demographic data.”[64] Continued improvements in how the health care system works for LGBTQI+ communities and reduced disparities in health status will prove beneficial to the entire population and health care system, while LGBTQI+ people and their families will benefit from diminished disease transmission and progression, increased well-being, reduced health care costs, and increased longevity.[65]

 

Medicaid and LGBTQI+ Communities

The Medicaid program is a critical source of health care coverage for LGBTQI+ communities. Before 2014, when many states expanded Medicaid as a result of the ACA, many LGBTQI+ individuals with low incomes did not have access to health coverage. Medicaid expansion heralded a drop in uninsurance rates among lesbian, gay, and bisexual adults of nearly 50 percent by one estimate.[66] A 2014 study by the Center for American Progress surveying LGBT adults with incomes below 400 percent of the federal poverty level found that 61 percent fell within the Medicaid expansion range, with even higher rates of potential eligibility among Black and Latino respondents.[67] By 2017, nearly 1.2 million LGBT adults aged 18 to 64 used Medicaid as their primary source of health coverage, and people identifying as LGBTQ+ were 1.6 times more likely than non-LGBTQ individuals to report using Medicaid for themselves or their family.[68],[69]

Two key Supreme Court decisions of 2013 and 2015 influenced Medicaid eligibility for LGBTQ+ families. The overturning of the federal Defense of Marriage Act (DOMA) in 2013 required federal recognition of same-sex marriages, but did not require states or private insurers to recognize them. Not until the Obergefell ruling in 2015, which required the recognition of same-sex marriages by states, were Medicaid and CHIP programs universally available to qualifying LGBTQ+ families.[70]

Medicaid is largely unavailable to childless adults in states that have not adopted ACA expansions. This leaves many LGBTQ+ adults, over 70 percent of whom are not raising children, uninsured.[71],[72] Additionally, many of the estimated 640,000 LGBTQI+ immigrants living in the U.S. lack access to Medicaid, since lawful permanent residents are not eligible for Medicaid until five years after established residence.[73]

The ACA established protections in commercial health coverage for people with pre-existing conditions, such as HIV.[74] In addition, regulations promulgated in 2016 interpreting Section 1557 of the ACA prohibited discrimination on the basis of sex, specifically defined to include sexual orientation, gender identity, and sex characteristics (including intersex traits). These rules also clarified that Medicaid and other federally-funded programs must cover and provide access to services for transgender individuals, without discriminatory exclusions.[75],[76] The 2016 rule cited several then-recent court rulings, as well as guidelines and recommendations from medical associations. Revisions to the nondiscrimination rule finalized in June 2020 removed references to these protections for LGBTQI+ populations, citing a 2019 Texas federal court ruling holding that the ACA does not prohibit anti-transgender discrimination and that religiously-affiliated plans are entitled to broad exemptions from nondiscrimination requirements.[77] The rule also questioned HHS’s own prior findings regarding the necessity and cost-effectiveness of gender-affirming care. In August 2020, however, two federal court rulings blocked the deletion of rule language on gender identity discrimination, citing the 2020 Bostock Supreme Court ruling.[78] Based on these rulings, the Biden Administration announced in May 2021 that would enforce the ACA in accord with Bostock and undertake new rulemaking to again recognize these protections.

Prior to enactment of the ACA, insurance plans often considered being transgender to be a disqualifying pre-existing condition for those seeking a health plan, and categorically excluded coverage of gender-affirming services for transgender individuals, including surgeries, hormone replacement therapy, and any mental health counseling related to gender transition.[79] Today, gender-affirming care is accepted as medically necessary for transgender individuals with gender dysphoria.[80],[81] In 2010, the U.S. Tax Court ruled that gender affirming surgeries are treated identically with other deductible medical expenses.[82] In 2014, an HHS appeals board overturned an exclusion of all gender-affirming surgeries under Medicare.[83],[84] Prior to the 2020 rule change, Section 1557’s sex discrimination protections, along with state policy changes, led to advancements in coverage for LGBTQI+ people, especially transgender individuals, as well as increased equity and inclusion efforts by provider institutions. HHS also provided guidance to plans on the use of automatic gender-based claim edits, which often cause transgender and intersex consumers to experience coverage denials for preventative and other services typically associated with one gender, such as a transgender woman who needs prostate care, or a transgender man who needs a Pap smear.[85],[86],[87],[88],[89],[90],[91],[92],[93] However, following the 2020 rule changes, some insurers have modified their plans to reinstate discriminatory exclusions.[94]

Despite recent progress, transgender and intersex people continue to face many barriers in the health care system, from discriminatory policies to harassment in clinical settings to reluctance to seek care. As mentioned previously, many transgender and intersex patients are fearful of being mistreated or turned away by providers or clinical staff. These fears of stigma and discrimination are compounded when a patient is an also immigrant or ethnic or racial minority.[95] As of June 2021, eleven state Medicaid programs are in violation of the nondiscrimination rule by continuing to exclude coverage of gender-affirming care.[96]

 

Safety Net Health Plan Efforts Address Coverage and Care for LGBTQI+ Individuals: Case Studies

In 2018, nearly 1.2 million LGBT adults were estimated as having Medicaid as their primary source of health insurance, equaling almost 12 percent of the LGBT adult population.[97] More than eighty percent of all people enrolled in Medicaid receive their coverage from Medicaid managed care organizations or primary care case management. A 2020 survey of Medicaid managed care organizations by the Institute for Medicaid Innovation found that in 2019, 60 percent of Medicaid managed care organizations offer a targeted program to address sexual and gender minority health, and another 20 percent were considering doing so.[98]

The Association for Community Affiliated Plans (ACAP) represents 78 Safety Net Health Plans across the nation, which collectively cover nearly one-third of all individuals in Medicaid managed care. Several ACAP-member Safety Net Health Plans (SNHPs) have forged efforts to end discrimination and close coverage gaps for LGBTQI+ individuals. These plans have engaged in advocacy, implemented programming, and adopted enterprise-level policies to address barriers to health care, increase training for providers, and ultimately, decrease disparities in care for LGBTQI+ individuals.

The following case studies provide examples of Safety Net Health Plan efforts to positively address inequities in health care for LGBTQI+ individuals with Medicaid coverage.

 

Children’s Community Health Plan

Children’s Community Health Plan (CCHP) is a not-for-profit health plan owned by Children’s Hospital and Health System in Milwaukee. The plan serves Medicaid members in 28 counties in eastern Wisconsin. In 2017, CCHP began offering individual and family plans in southeastern Wisconsin through the health insurance Marketplace. CCHP is the second largest Medicaid health plan in the State, serving more than 125,000 people in Medicaid and 15,000 Marketplace members. CCHP has a network of more than 10,000 providers and 50 hospitals.

CCHP is focused on improving the health and well-being of its members by providing access to a broad network of health services and providers, as well as prevention programs. The plan’s high-touch philosophy shows through its continuous outreach to members to ensure they receive needed services in a timely and cost-effective manner. CCHP staff continually strive to exceed expectations during each interaction with members and providers.

Cultural Competency Practices

CCHP adheres to cultural competency practices, inclusive of LGBTQ competency development, that are articulated in its own Policy and Procedure guidelines. These comprise standard nondiscrimination language and detailed requirements for staff, including participation in two cultural competence-related courses each calendar year. These courses were developed by the Children’s University and Children’s Hospital and Health System and are designed to assist staff to better understand and serve members based on culture and diversity.

In addition to mandating cultural competency training, CCHP follows original ACA Section 1557 nondiscrimination guidelines and includes nondiscrimination language in marketing materials and all other consumer documents, including an “excellence of care” statement, customer service letters, on its Web site, and in its plan documents. CCHP’s cultural competency policy is also published on its Web site, where nondiscrimination language is visible to the public.

Diversity Committee and Staff Education Summit

As part of a broad initiative focused on cultural competence, CCHP established a Diversity Committee in response to staff and leadership requests for further education and training on diversity and inclusion. The first topic the Diversity Committee addressed was the need for training on LGBTQI+ health and health disparities.

The Diversity Committee held their first all-staff education summit in 2019 focused on the needs of LGBTQ members and featuring a panel centered on LGBTQ health with community leaders and experts, including providers and patients, many of whom were members of LGBTQ communities. Panelists shared their experiences with the health care system as members of LGBTQ communities. The panel presentation encouraged a deeper understanding of unique whole-health needs for LGBTQ individuals, including barriers to care, appropriate language, and cultural nuances. An open question-and-answer session allowed panelists to respond to a wide range of questions from plan staff. Panelists provided ideas for creating a friendlier member experience, including providing gender-neutral bathrooms, hiring providers and staff familiar with LGBTQ communities, and finding ways to have fun with these topics. Panelists educated staff on the importance of buy-in by plan leaders for LGBTQ-focused initiatives. CCHP established expectations that all plan staff, regardless of job title or role, attend the summit as part of a broader series of interactive educational and development opportunities, and reports that over 90 percent of plan staff were in attendance. The vast majority of attendees thought the discussion was worthwhile and applicable for all staff roles.

Since the first summit, the Diversity Committee has held additional events for all staff. Diversity and equity have become a major priority built into their system infrastructure, with many initiatives across the Children’s Hospital and Health System. This includes a stand-alone department, with a Vice President of Inclusion, Diversity, and Equity who reports directly to the CEO. CCHP is significantly involved in and leading several initiatives within this department.

After the success of the first staff education summit, CCHP engaged one of the panel members, a CCHP network provider, to co-write an article on provider best practices for LGBTQ-competent care and treatment for inclusion in the provider newsletter, accompanied by a link to the recorded LGBTQ panel discussion. CCHP hopes to also include these resources on their Web site for their 12,000 providers to access at any time.

Other Resources, Outreach, & Programs

CCHP has made an internal staff LGBTQ resource list available throughout the Children’s University and Children’s Hospital and Health System, which includes links to Web sites for LGBTQ patients and their family and friends with information on support groups, a crisis hotline, and other educational services. The one-page handout can be easily distributed to patients and their families in person or online. A more refined list of these resources is currently being developed for CCHP staff by the CCHP Health Management Team.

CCHP also recognizes the importance of engaging with community-based organizations to establish trust with LGBTQI+ communities. CCHP and Together with CCHP, the plan’s Marketplace product, were featured inside the Health and Wellness Tent at PrideFest 2019 in Milwaukee as a trusted resource to LGBTQI+ communities. They also stay engaged at “Community Game Nights” and sponsored the 2019 Big Night Out Celebration, an event to raise LGBTQI+ awareness. Additionally, CCHP and Together with CCHP are listed as preferred health insurance providers of the Milwaukee LGBT Community Center. These partnerships were developed through outreach from member advocates as well as the plan community engagement team and staff interested in LGBTQI+ member needs. With the perspective that all CCHP stakeholders – staff and network providers alike – can strive to become more culturally competent, CCHP is working with those who specialize in this area on collaborative trainings and outreach to promote their service utilization with members.

Future Direction

CCHP surveyed staff to gather responses to the education summit; the results of the survey will inform planning for future diversity trainings. The plan also calls for tracking interest in certain topics by monitoring accesses to the link to the recorded panel discussion as well as their future provider-centered article. CCHP plans to identify methods to measure satisfaction and health outcomes for LGBTQ members, and intends to improve data collection on this population to help improve quality of care, mitigate disparities, and increase health care engagement. The plan intends to update marketing materials and train staff to better serve this population in the future. Like many other plans, CCHP’s current approach to LGBTQI+ cultural competency is from the inside out: many initiatives start with motivated plan staff that identify needs and make suggestions. Overall, CCHP’s goals are to be friendly, aware, and sensitive when working with LGBTQI+ communities.

 

VNSNY CHOICE Health Plan

A component of the Visiting Nurse Service of New York (VNSNY), VNSNY CHOICE Health Plans’ mission is to improve the health and well-being of people through high-quality, cost-effective health care in the home and community. A leader in caring for complex populations, VNSNY CHOICE Health Plans include a Medicaid Managed Long Term Care (MLTC) plan, a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP), and a Medicaid HIV Special Needs Plan (HIV SNP) called SelectHealth. SelectHealth provides culturally competent and comprehensive care to 3,000 enrollees individuals who are HIV positive, or transgender or homeless regardless of HIV status. Though complete demographic data on LGBTQI+ status is not available, most HIV SNP enrollees are believed to LGBTQ+.

SelectHealth serves all five boroughs of New York City, Long Island, and Westchester County. This is happening at time when HIV and AIDS diagnoses are decreasing. Currently, SelectHealth is the only HIV SNP serving members outside New York City.

HIV Special Needs Plan

Perceiving a need for specialized health coverage among members impacted by HIV/AIDS, New York State developed HIV SNPs, a unique coverage model initially designed to serve the HIV-positive population and expanded to cover transgender people and people who are experiencing homelessness regardless of HIV status. As a specialized Medicaid plan, SelectHealth covers a full range of physical and behavioral health care as well as social support services. SelectHealth has in its provider network various designated AIDS centers (DACs), Federally Qualified Health Centers (FQHCs), and solo practitioners who specialize in HIV care.[99] SNP members who are HIV+ are linked with an HIV specialist as primary care provider and pre-approved for HIV prescriptions to prevent the need for prior authorization. All SNP members receive individualized care management and support from plan pharmacists to support medication adherence.

People living with HIV can achieve viral suppression through effective treatment, and a suppressed state is commonly referred to as “undetectable,” and a person with a suppressed viral load cannot transmit HIV to others. Nearly six out of seven SelectHealth members – 84 percent of HIV+ enrollees — have achieved complete viral load suppression, the highest rate among New York HIV SNPs.[100],[101]

SelectHealth employs a field-based outreach team that works with DACs, FQHCs, community-based organizations, and individual practitioners to help enroll eligible individuals throughout its service area. SelectHealth also has a peer partnership with a community-based organization to encourage members experiencing care gaps and complex health issues to return to care. These peers work one-on-one with individuals for as long as necessary until barriers to care are eradicated.

SAGE Credentialing

In 2018, VNSNY became the first organization serving New York City, Nassau, Westchester, and upstate New York to receive Platinum-level certification from the LGBT advocacy group SAGE (Services and Advocacy for LGBT Elders). The Platinum credentials, SAGE’s highest certification, indicates that 80 percent or more of employees have successfully received SAGE’s LGBT cultural competency training, demonstrating the organization’s commitment to treating community members with respect, understanding, and sensitivity. Every part of the broader VNSNY organization is SAGE-credentialed at the Platinum level.

VNSNY CHOICE Health Plans regularly partners with its sister provider affiliates to fulfill its commitment to LGBTQ+ communities. The VNSNY parent organization developed the Gender Affirmation Program (GAP). The first program of its kind in the United States, GAP’s specialized nurses are trained to provide home care to transgender individuals who have undergone gender affirming surgeries. During their recovery, GAP nurses provide social and medical support to ensure members recover properly and remain socially engaged.

Community-Based Partnerships

VNSNY understands the importance of working with community-based organizations throughout the State to disseminate information to LGBTQ+ members and provides LGBTQ+ health presentations to a wide range of organizations.

VNSNY’s Senior LGBTQ+ Outreach Program involves collaborations with over 40 community-based organizations serving elderly LGBTQ+ individuals as well as hospitals and clinics that serve New York’s elderly LGBTQ+ population. Many LGBTQ+ elders still fear coming out where they live or at senior centers; VNSNY offers LGBTQ health presentations at these sites, providing culturally sensitive information for senior patients on health care risks such as HIV, cardiac status, and diabetes at FQHCs, nursing homes, and other provider locations. These efforts aim to educate senior LGBTQ+ members directly about health risks as well as alleviate fears of the health care system, and have also allowed VNSNY to better understand the challenges experienced by elderly LGBTQ+ members.

VNSNY and SelectHealth also sponsor and participate in many LGBTQI+ public events, such as the AIDS WALK New York, the New York City PRIDE March and PRIDE events in New York communities. At these events, the organizations educate members of the LGBTQI+ and HIV communities about available VNSNY products and services. The importance of working with well-established groups to build trust among LGBTQI+ individuals has been an ongoing component of partnership development for SelectHealth and VNSNY’s other plans, products, and programs.

Future Plans

VNSNY plans to further the reach and depth of its LGBTQ+-based programs. Staff hope to hold more community presentations and classes based on needs identified in member questionnaires. SelectHealth is also continuing to reach eligible individuals who are unaware of the supports that HIV SNPs provide, encourage enrollment, and explore barriers preventing enrollment. SelectHealth operates a reward program for members in line with Undetectable = Untransmittable CDC guidelines, incentivizing individuals to maintain health by undergoing appropriate screening and provider visits.[102] SelectHealth will continue to use texting, social medial platforms, and a digital marketing campaign to further engage members and potential members.

Because enrollees are deemed ineligible upon becoming Medicare-eligible, SelectHealth is also working to address challenges members experience as they age out of the HIV SNP.

VNSNY is committed to continuing its work with the community and New York State to create the best possible coverage and care for LGBTQI+ members.

 

San Francisco Health Plan

San Francisco Health Plan (SFHP) provides affordable health coverage to over 145,000 low and moderate-income families in San Francisco County. Members are covered for a full spectrum of medical services, including preventative care, specialty care, hospitalization, and family planning services. SFHP also services the City’s award-winning access program, Healthy San Francisco, which has served over 50,000 people. SFHP was created by the City and County of San Francisco with the purpose of providing high-quality coverage to the largest number of low-income San Franciscans possible and lowering overall costs while supporting San Francisco’s community-minded doctors, clinics, and hospitals. SFHP takes great pride in its ability to serve a diverse population.

Many of SFHP’s LGBTQI+ members struggle with mental health and substance use disorders, in addition to HIV, hepatitis C, STIs, and relationship or other types of physical abuse. Many of the plan’s transgender members engage in sex work that is criminalized and stigmatized, posing unique challenges to care. Only certain clinics in the public health system have built trust with the LGBTQI+ community, and this is particularly true among members who are sex workers, IV drug users, or who have behavioral health conditions. SFHP has noticed that clinics with integrated behavioral health services are better equipped to serve the LGBTQI+ community.

SFHP strives to identify LGBTQI+ plan members to provide adequate resources and access to care, often working with community-based clinics to identify LGBTQI+ patients. Recognizing the importance of measuring outcomes for transgender patients in particular, SFHP collaborates with the San Francisco Department of Public Health in San Francisco to exchange data on health care services for these members.

 

Program Creation

SFHP has established initiatives to combat health disparities and discrimination among its LGBTQI+ members. For the past five years, SFHP’s partnership with the Department of Public Health’s Gender Health San Francisco program has addressed barriers to care, establishing provider training programs and a multidisciplinary approach to working with members to access services at both Zuckerberg San Francisco General Hospital (ZSFG) and University of California San Francisco (UCSF) Hospital. The collaboration catalyzed the creation of educational and peer navigator programs for transgender members seeking services, with staff who are paid by the Department of Public Health providing information on benefits, access, and procedures.

SFHP has also worked with the World Professional Association for Transgender Health (WPATH) to develop guidelines for gender affirming services such as genital surgeries and hair removal, and has promoted guidelines to remove all gender edits from medical and pharmacy claims payment systems.

Building these programs came with many challenges, including securing funding and office space, and finding leaders – including experts who are transgender individuals as well as non-transgender-identifying individuals – for workshops or training navigators. SFHP uncovered a need for better regulations surrounding coverage of gender affirmation surgery and identified that many transgender patients experienced significant problems securing housing following surgery. A team of SFHP nurses took initiative, securing medical respite and longer-term housing for members recovering from gender affirmation surgeries. The team’s efforts also led to new training for behavioral health specialists and expansion of the program to hospitals, including UCSF and ZSFG, as well as development of a brochure for transgender patients that included frequently asked questions. This team also worked with clinics that had rapport among transgender patients, working toward increasing access, bettering outcomes, and establishing trust.

 

Provider Training

SFHP has expanded its provider network to include practitioners with expertise in LGBTQI+ health care and strives to increase this expertise among existing network providers. SFHP also employs a full-time prior authorization gender affirming services nurse specialist who provides training to primary care and behavioral health providers focused on caring for transgender and non-binary members and providing a holistic approach to treating LGBTQI+ community members. These trainings teach network providers about the health plan’s benefits and how to help members access services.

Implementation of provider training was initially slow, challenged by low acceptance among providers and a lack of dedicated funding. Eventually, training was expanded with funding from the San Francisco Health Network, a hospital and clinic network closely affiliated with the Department of Public Health.

SFHP has used incentives such as a practice improvement program and surplus funding to encourage better care by providers for LGBTQI+ members. SFHP also extends cultural sensitivity training to all health plan staff focused on working with LGBTQI+ members.

 

Services, Programs, & Challenges

Through hospital and community partnerships, SFHP has been able to implement several programs and services for LGBTQI+ members, and with a special focus on transgender members. For example, SFHP schedules daily phone calls between SFHP Clinical Operations Nurses and Patient Navigators located at the two hospital clinics to discuss program successes and challenges. SFHP partners with ZSFG’s Gender Health Clinic and USCF’s Transgender Clinic to offer patient education classes and individual navigators to help members understand their Medi-Cal benefits, member rights, provider network, and the clinical benefits and risks of gender affirming care options. Additionally, SFHP participated in UCSF’s biennial National Transgender Health Summit this year—which brings together leading clinical, community, and academic experts—and served as a resource by answering questions from local providers.

SFHP has regular reviews with ZSFG’s Gender Health Clinic and UCSF’s Transgender clinic on clinical outcomes related to gender affirming services to improve outcomes and refine programs. Through these reviews, the plan has noticed an increase in transgender service requests and better access.

Despite growth and many successes, SFHP continues to experience challenges engaging LGBTQI+ members. Many transgender members still delay or forego medical services, including preventative care, out of fear of discrimination, and gaining the trust of some members still proves difficult. SFHP has found the most success by working with already-established community programs and hospitals that work closely with LGBTQI+ communities.

 

Future Direction

SFHP intends to expand its LGBTQI+ health programming and to extend training and practice improvement efforts to increase cultural competency among network providers. High provider turnover in teaching hospitals requires an ongoing effort. Better care navigation for transgender members is needed, as well as additional collaboration with well-established community organizations. The plan intends to expand gender health programs to more hospitals and clinics, possibly including hospitals outside of SFHP’s network.

Because plan members currently must visit out-of-network hospitals that are often outside of San Francisco to obtain gender affirming surgeries, SFHP also hopes to soon provide access to gender affirming surgical services in a local setting. To this end, SFHP is currently working with San Francisco Health Network to integrate this care.

 

Amida Care Health Plan

Amida Care is a private, not-for-profit community health plan that specializes in comprehensive health coverage and coordinated care to New York City Medicaid members with chronic conditions, including HIV/AIDS and behavioral health disorders. Six community-based New York City HIV/AIDS providers united to develop and launch Amida Care (then Vida Care) in 2003 with support from the AIDS Institute and the New York State Department of Health. The plan currently serves more than 8,500 members throughout the five boroughs of New York City, including people living with HIV/AIDS, people experiencing homelessness, and transgender people.

Amida Care has developed a specialized model of care to provide individualized attention and support to people living with HIV/AIDS and other complex health conditions. People experiencing homelessness regardless of HIV status are also eligible to enroll, and in 2017, the plan expanded to provide access to all eligible transgender individuals regardless of HIV status. Today, Amida Care is the largest Medicaid Special Needs Health Plan (SNP) in New York State. As a result, Amida Care’s high-touch model of care is now available to more transgender individuals, who often experience significant barriers to care. The expansion supports the goals of New York State’s Blueprint to End the HIV/AIDS Epidemic (ETE).[103]

Demographics and Member Health Trends

From its origins, Amida Care has served many LGBTQI+ individuals and populations placed at risk of HIV: MSM of color, both Latino and African-American; women of color; people of transgender experience; and people with substance use disorders. Amida Care has over 770 transgender members who are HIV-positive, and since Amida Care’s 2017 eligibility expansion, Amida Care has enrolled over 1,000 transgender members who are HIV-negative. Amida Care now serves a significant transgender population, representing 23 percent of its total membership.

Almost 90 percent of Amida Care’s members are eligible for the New York State program Health Homes, a Medicaid state plan care model that involves the coordinated care of an individual’s overall health care needs. Amida Care works with this program to put people on the road to wellness by providing care management and coordinated access to care, connecting people with primary care, and providing access to specialty providers, including the full spectrum of behavioral health services and supportive services that address social determinants of health. A significant percentage of Amida Care’s covered population has comorbidities such as behavioral health issues, including substance use disorder and depression. The plan employs a dedicated team focused on behavioral health to address these issues.

Amida Care helps its members living with HIV achieve and maintain viral suppression. Viral load suppression among Amida Care members has increased from 64 percent in 2016 to more than 80 percent in 2019. Of Amida Care’s transgender members living with HIV, 93 percent are virally suppressed. The plan has also observed decreased numbers of emergency room visits, decreased average length of stay in hospitals, and generally lower utilization of intensive care resources, which has produced significant cost savings to New York State.

Member-Focused Care

To best serve transgender people, Amida Care reassessed authorization processes for both hormones and gender affirming surgeries to mitigate barriers in care access; this effort resulted in the development by Amida Care of Clinical Guidelines and Coverage Criteria for the Treatment of Gender Dysphoria. that were approved by the State’s Department of Health. Amida Care’s high-touch model of care – in which Amida Care supports members in accessing needed services, assists members in securing letters of support necessary for gender affirming surgeries, and assists with paperwork – has led to a significant increase in people accessing these services. In 2021, over 1,160 of Amida Care’s transgender members have had one or more gender-affirming surgery. These surgeries set members on a path towards wellness that is manifested in higher-than-average viral load suppression among those living with HIV.

Amida Care has established Integrated Care Teams to help individual members navigate the health system. Community Health Outreach Workers go out into communities and directly engage with members where they live and encourage them to stay in care, take prescribed medications, and follow a wellness plan. Integrated care teams are typically led by a nurse, and members can reach out to these teams for consultations. Additionally, Amida Care offers a specialized support team specifically for transgender members and provides several publications on its website to help transgender members access the care and coverage they need.[104]

Amida Care offers HIV-negative members sex-positive health screenings, including HIV assessments, during their first six months of enrollment. Amida Care also provides health education on HIV prevention treatment for individuals placed at elevated risk for HIV. HIV prevention treatment involves providing medication either before or after a person is exposed to the HIV virus, (PrEP) or Post-Exposure Prophylaxis (PEP). Among HIV-negative transgender members, nearly 20 percent have started PrEP. The plan’s Health Services and Pharmacy Departments collaborate to provide “first fill” counseling and monitor claims activity for adherence.

Amida Care ensures that all plan communications are culturally inclusive. The plan publishes sexual health information to inform members of available services, promote inclusivity, and detail Amida Care’s dedication to preventing discrimination. The plan additionally hosts monthly member town halls allowing the plan an opportunity to directly communicate with members, receive feedback on cultural competency, and hold trainings.

To ensure that member needs are heard and met, Amida Care additionally created a Member Advisory Council (MAC), consisting of 35 plan enrollees from many of Amida Care’s primary care sites. The MAC has an active role in advising member service initiatives for the plan and serves as a cultural competency advisory committee. There is strong LGBTQ representation on the MAC. The MAC also elects two of its members to serve on Amida Care’s 11-person Board of Directors.

Staff Training

Because Amida Care serves a large LGBTQI+ population, the entire staff must be trained in cultural competency. Amida Care arranges town halls for staff featuring experts on transgender cultural competency training, including sensitive usage of pronouns, assumptions of gender identity, and misgendering. New staff at Amida Care also undergo Section 1557 nondiscrimination training.

Provider Collaboration

To support its providers’ efforts to provide culturally-appropriate care to their patients of transgender experience, Amida Care developed Breaking Barriers to Transgender Health Care: A Report on Health Challenges and Solutions for the Transgender Community. This report quantifies the impact of systemic discrimination in health care against transgender people and offers providers techniques and principles for delivering more-inclusive care for people of transgender experience. Amida Care offers on-site training to providers and is currently assessing provider training needs—including transgender competency training.

Amida Care also sponsors community events to deliver education and resources to health plan members and potential members. The plan sponsors a Transgender Health Conference in New York City in collaboration with Community Healthcare Network, one of Amida Care’s providers. Amida Care is also working to expand access to gender-affirming surgeries with several of its providers, including Callen-Lorde Community Health Center, a federally qualified health center that serves New York’s LGBTQ communities. The plan also works with providers to teach members about surgery after-care and reduce complications, offers home care, including next day visits after discharge.

 

Advocacy and Outreach

Amida Care works to address disparities in social determinants of health faced disproportionately by LGBTQI+ and HIV communities. The plan produced an informational magazine called ‘Hire Me’ to address higher rates of unemployment among people with HIV. Amida Care also offers job training and employment placement programs, and has housing specialists on staff to provide housing referrals to members. The plan connects transgender members with resources to assist with food insecurity and for legal issues such as managing name changes and to address other social determinants of health. Amida Care also partners with the Transgender Legal Defense and Education Fund and other community-based organizations so that members may access needed legal services.

Amida Care participates in LGBTQI+ Pride events to reach younger members and elevate their community presence. The plan has sponsored events with the Kiki Coalition in NYC, a group of community-based organizations that provide support for LGBTQI+ youth.

Amida Care’s policy team supports local, state, and federal advocacy to protect LGBTQI+ health care and other rights. The plan is actively involved in efforts to End the HIV/AIDS Epidemic both in New York State and nationally. The plan also actively supported passage of New York’s Gender Expression Non-Discrimination Act (GENDA) in 2019. GENDA enshrines protections against discrimination based on sexual orientation or gender identity in state law. These protections are similar to those in the federal Section 1557 nondiscrimination regulations.

 

Challenges

As New York’s Medicaid program underestimated the need for gender affirmation services, Amida Care continues to advocate for adequate reimbursement rates for coverage of gender affirming services.

Currently, the health plan offers services related to social drivers of health that are not reimbursed as medical costs by Medicaid. This requires the plan to expend administrative funds that are subject to budget restrictions, limiting Amida Care’s ability to scale up services to facilitate better access to medical services. However, the State is working on a new roadmap for value-based care and has suggested that services addressing social determinants of health should be more broadly supported by Medicaid.

Future Plans

Amida Care hopes to expand to expand its services beyond the boroughs of New York City to additional New York State counties with high HIV incidence. Additionally, Amida Care aspires to a time when the plan can offer access to anyone who needs PrEP — and to reach a wider population before they become HIV-positive.

Amida Care is committed to full inclusion and elimination of discrimination in all forms, from the people they employ to the people they serve. The plan will continue to develop, promote, and sustain a culture that values equality and leverages diversity and inclusiveness.

 

University of Pittsburgh Medical Center Health Plan – UPMC for You

UPMC for You and UPMC Health Plan are a part of the University of Pittsburgh Medical Center, an integrated health care delivery system. UPMC’s Insurance Services Division (ISD) is committed to providing members better health, more financial security, and peace of mind. The UPMC ISD — which includes UPMC Health Plan, WorkPartners, UPMC for Life, UPMC for You, UPMC for Kids, and Community Care Behavioral Health — offers a full range of group health insurance, Medicare, Special Needs, CHIP, Medical Assistance, behavioral health, employee assistance, and workers’ compensation products and services to more than 3.4 million members. The plan’s provider network includes UPMC as well as community providers, totaling more than 140 hospitals and more than 23,300 physicians throughout Pennsylvania and parts of Ohio, West Virginia, and Maryland.

UPMC continues to explore meaningful ways to incorporate sexual orientation and gender identity (SOGI) data collection into its care management, electronic medical record, and other systems. The plan currently gathers insight into the needs of LGBTQ members from data related to behavioral health support, puberty suppression services, and long-term services. UPMC Health Plan also recently conducted focus groups – through its Center for High Value Health Care – with LGBTQ community members to identify pressing member needs and potential solutions to provide better access to clinically and culturally competent care.

Dedicated Transgender Member Services Team

In 2017, UPMC developed a member services team with experts from across the plan’s operations who are specially trained to appropriately and effectively address the health needs of transgender members. In addition, the plan created a Transgender Task Force to ensure that transgender members have access to dedicated staff able to answer questions related to coverage, provider referrals, and gender-affirming care.

For inbound calls from transgender members and the providers who serve them, the Task Force has developed workflow maps regarding responses to benefit authorization questions, the need for care coordination, or other clinical requests. Team members provide transgender patients with information related to payment for gender affirming surgeries and help them and their providers navigate surgery authorizations. The Task Force provides a confidential space for enrollees to ask questions related to transgender-specific care. UPMC assures that the team members are culturally diverse and clinically competent.

Provider & Staff Training

UPMC noticed a need for cultural competency training among the hospitals and clinics that serve a significant proportion of UPMC members. To develop this training, UPMC staff collaborated with the Persad Center, a human services organization in Pennsylvania, and other LGBTQ+ community leaders. UPMC now offers an LGBTQ+ cultural competency training module and also partners with Persad and other groups to do in-person or virtual trainings for staff. The initial focus was for MLTSS staff, as these staff members and providers often interact first with members and on a very personal level – usually in member’s homes – but now is available to others across the integrated delivery and finance system. Training included guidance on member interactions, such as asking questions in an appropriate way and the sensitive use of correct pronouns. The plan expects to expand training to all UPMC coverage regions and for staff at all member touch points, including all staff that interact with patients.

Online LGBTQ Resources

UPMC’s Patient Experience Team led the development of the first dedicated website for LGBTQ health at UPMC, acting as a foundation to further communicate the plan’s commitment to the LGBTQ community. This website houses a list of culturally-competent providers across multiple specialties, and further serves as a guide to clinical care and supportive resources available to LGBTQ patients and caregivers.

UPMC engaged the online community vendor Smart Patients to build a forum focused on LGBTQ-related issues and questions for members. The forum acts as a navigation hub for LGBTQ community members, including potential members, and provides resources as well as space for productive conversation about LGBTQ issues. Led by the UPMC Patient Experience team, UPMC recruited an advisory group of internal and external experts to develop content and prepare technology that allows providers to respond to posted forum questions.

Both the LGBTQ+-focused website and the forum are paid for by the UPMC Patient Experience administrative budget. UPMC Health Plan views both efforts as fundamental business developments and accordingly have incorporated the cost of operations into their budget.

Accreditation and Provider of Excellence Certification

UPMC Health Plan received a 100 percent rating in the 2020 Human Rights Campaign (HRC) Corporate Equality Index (CEI) – the index for non-hospitals – for treatment of customers and employees. The HRC’s CEI awarded UPMC Health Plan a perfect score on workforce protections, inclusive benefits, and overall transgender health coverage.

With a grant from the Beckwith Institute, endowed by UPMC, the plan partnered with leaders across the integrated delivery and finance system to design a training process intended to help UPMC hospitals receive HRC Healthcare Equality Index (HEI) certification – the index specifically for hospitals and other offices where healthcare services are provided. This certification was developed to encourage the adoption of LGBTQ-inclusive patient, visitation, and employment policies to provide equitable care.

UPMC is additionally working in partnership with the Fenway Institute, international leaders in LGBTQ care, to create an LGBTQ Clinic/Provider of Excellence certification. This program will require clinicians to complete cultural competency and LGBTQ specific trainings based on their specialty. To develop this certification, UPMC met with four clinics with good outcomes related to the LGBTQ community to determine areas of excellence that could be taught to other providers.

Outreach and Collaboration

UPMC engages in several partnerships to ensure equitable care and gain further understanding of potential positive interventions and strategies. UPMC is represented on the Pennsylvania Governor’s Commission on LGBTQ Affairs, which advises the Governor and State agencies regarding policies, programs, and legislation impacting LGBTQ communities. UPMC also participates in a statewide Transgender Health Work Group led by the LGBTQ Commission that focuses on changes to transgender health care specifically.

UPMC works with many organizations, both LGBTQ-affiliated and non-LGBTQ-affiliated, to provide comprehensive care. The plan has noticed a heightened importance of collaboration with LGBTQ community centers especially in rural areas where access to care may be more limited. Additionally, due to an increased number of senior members, UPMC collaborates with long-term care facilities to improve the quality of services and supports offered to LGBTQ+ older adults.

Future Plans

UPMC’s goal is to continue creating a comprehensive network of providers for LGBTQ members. Without dedicated accreditation for clinicians providing LGBTQ+ services, it is difficult to guarantee standards of care or previous diversity training; UPMC plans to continue implementing these trainings across plan networks. The plan additionally has noticed a lack of providers in the area that offer comprehensive care for transgender members, including necessary surgeries. UPMC hopes to continue expanding their provider network to cover all components of gender assignment surgery.

Over the next decade, UPMC hopes to close gaps in health disparities for the LGBTQ community, with progress driven by lessons learned from individual experiences. UPMC will continue to use focus groups to ensure efforts are driven by community need, participation, and partnership. UPMC intends to become a model for the nation on how a health plan and an integrated delivery and financing system can care for and support the LGBTQ community.

 

 

 

Conclusion

LGBTQI+ communities have made substantial progress in recent years toward ending discrimination and improving access to quality, affordable health care. As summarized in this report, this progress can be seen in the enactment of the Affordable Care Act; nondiscrimination rules and guidance implementing Section 1557 of the ACA and other laws; numerous court rulings affirming the validity of LGBTQI+ experience and prohibiting discrimination on the basis of sexual orientation, gender identity, and sex characteristics (including intersex traits); and efforts by health plans and providers across the country to change policies, coverage, systems, and culture to better serve LGBTQI+ people and their families.

Still, a great deal of work remains to be done. Efforts are underway in the Medicaid program to promote health equity for LGBTQI+ communities. Specifically, Medicaid health plans are taking key steps to reform the health care that their LGBTQ+ members receive, including:

• Providing comprehensive coverage of all medically necessary gender affirming benefits and services.
• Offering targeted member services, including peer navigation supports, LGBTQI+-focused publications, online resources for members and families.
• Establishing partnerships with existing community providers with expertise in serving LGBTQI+ communities and extensive provider training.
• Formation of advisory councils including members of LGBTQI+ communities.
• Conducting community outreach, including involvement in Pride events, balls, and other community events.
• Establishing employee committees focused on diversity, equity, and inclusion; conducting extensive cultural competency employee training; and developing professional standards for staff focused on health equity—including, but not limited to, a focus on serving LGBTQI+ communities.
• Certification of plan operations by LGBTQI+ organizations.
• Undertaking regulatory advocacy focused on Medicaid programs to ensure access to gender affirming care.

The work to ensure that Federal and state health care policies offer protections against discrimination against LGBTQ+ people clearly is ongoing, but by establishing LGBTQI+ equity as an integrated effort across all plan operations, Medicaid health plans can and are making progress toward that end.

 

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