September 30, 2015 Kevin Counihan Deputy Administrator and Director, Center for Consumer Information and Insurance Oversight Centers for Medicare and Medicaid Services 7500 Security Boulevard Baltimore, MD 21244 Via email: [email protected] Re: 2017 Texas Essential Health Benefits Benchmark Plan Comments: Special Concerns re: Transgender Persons Dear Mr. Counihan: The Texas-based organizations signed onto this letter appreciate the opportunity to comment on proposed Texas Essential Health Benefit (EHB) benchmark for 2017 released on August 28, 2015. We fully endorse the comments submitted by the LGBT State Exchanges Project at the Center for American Progress (Washington, DC) which provide a detailed analysis of concerns about the potentially discriminatory impact of the non-compliant benchmark plans on access to services needed by transgender individuals in Texas and other states. We also fully endorse the comments submitted by Center for Public Policy Priorities (Austin, Texas), which detail fully the multiple shortcomings of Texas’ non-compliant default benchmark plan. Our organizations submit this separate comment letter to underscore our serious concern about the inadequacy of Texas’ EHB benchmark in its potential impact on transgender persons. Texas’ default EHB benchmark contains an exclusion for any services or supplies provided for, in preparation for, or in conjunction with “transsexual surgery.” We also note that Texas’ benchmark plan covers benefits for tests to detect Human Papillomavirus and cervical cancer including a Pap smear only for women age 18 and older. In addition to the arbitrary age limit which may be discriminatory, it is important that CCIIO clarify that these wellness services must be provided to any person with a cervix to be compliant with nondiscrimination requirements in ACA Section 1557 (see CAP comments). A number of other similar issues will arise when an insurer’s coverage description appears to limit any benefit to a particular gender. We join other groups in calling on CCIIO to explicitly clarify the requirement that services not be denied or limited as a result for transgender individuals. Texas consumers must rely on CCIIO to ensure that the state’s EHB benchmark conforms to federal law and will facilitate access to a comprehensive set of health care benefits in 2017 and beyond. Because Texas did not actively select a 2017 benchmark plan, nor did our state conduct a public process to collect public input on benchmark options and missing EHB categories, this comment opportunity is our first and perhaps only avenue for public input. As you know, Texas defaulted to the largest small group plan from 2014, which falls under the CCIIO’s transitional policy for non-grandfathered small group policies, meaning it is not required to comply with all ACA consumer protections, including EHB. As such, the automatic default benchmark plan retains 1 policies that would limit access to care for transgender Texans which are no longer allowable in the Marketplace. We underscore the point made by our CAP and CPPP colleagues, that Texas requires special attention because we are just one for five “direct enforcement” states that have elected not to enforce ACA consumer protections for health coverage policies sold in the state. Texas consumers are therefore relying entirely on the federal government to enforce all ACA health insurance market reforms, including these key protections for transgender persons. We join other Texas organizations in respectfully calling for CCIIO to take these steps to ensure that Texans with plans subject to EHB in 2017 and beyond will benefit from the full extent of benefits guaranteed by the ACA: • CCIIO should independently review Texas’ proposed benchmark’s evidence of coverage and other plan documents and identify specifically where the plan falls short of compliance with ACA regulations and guidance. • CCIIO should share the findings of its detailed review with issuers, so that they are on notice about where alignment with the benchmark would violate federal standards and preclude plan certification. CCIIO should also share its findings with the Texas Department of Insurance and make it publicly available to facilitate engagement of stakeholders in evaluating plan designs. • In Texas, CCIIO is solely responsible for reviewing and approving forms for QHPs offered in the Marketplace. CCIIO must carefully review plans submitted for certification in direct enforcement states and then take action ensure that coverage complies with all ACA market reforms and reflects the full scope of EHB. Thank you for the opportunity to comment on these important issues. If you have any questions or need further information, please contact Liz James at Lesbian Health Initiative of Houston, Inc. at [email protected] or 713-256-0044; or Anne Dunkelberg at [email protected] or 512 823 8264. Sincerely, Liz James, Chief Executive Officer Miriam Nisenbaum, Executive Director Lesbian Health Initiative of Houston, Inc. National Association of Social Workers – Texas 713-256-0044 direct Chapter 713-426-3356 office 810 W. 11th St., Austin, TX 78701 832-529-2555 fax (512) 474-1454 [email protected] [email protected] www.lhihouston.org www.naswtx.org Ann J. Robison, PhD, Executive Director Anne Dunkelberg, Associate Director The Montrose Center Center for Public Policy Priorities 401 Branard Street, 2nd Floor | Houston, TX 7020 Easy Wind Dr., Suite 200 ● Austin, TX 77006-5015 78752 713.529.0037 512 823-2864 desk [email protected] [email protected] www.montrosecenter.org www.cppp.org 2 Graciela Isabel Sanchez Ana R. DeFrates, Director Esperanza Peace and Justice Center Texas Latina Advocacy Network (LAN) Policy & 922 San Pedro Ave, San Antonio, TX 78212 Advocacy 210-228-0201 National Latina Institute for Reproductive [email protected] Health www.esperanzacenter.org (512) 963-6001 [email protected] Bob Kafka www.Latinainstitute.org ADAPT of Texas 1640A East 2nd St Andrea Caracostis, MD, MPH, Chief Executive Austin, Texas 78702 Officer 512 442 0252 HOPE CLINIC [email protected] 7001 Corporate Dr. Suite 120 www.adaptoftexas.org Houston, TX 77036 713-337-3641 Nell Gaither, President [email protected] Trans Pride Initiative www.hopechc.org P.O. Box 3982, Dallas, Texas 75208 214.449.1439 Elizabeth Colvin, Director [email protected] Insure Central Texas visit our Trans Health Empowerment site! A program of Foundation Communities 3036 S 1st St, Austin, Texas 78704 Marlen J. Trujillo, MBA, Chief Executive Officer 512-554-4409 Spring Branch Community Health Center [email protected] 800 W Sam Houston Parkway S, Suite 200 www.InsureCentralTexas.org Houston, TX 77042 713-462-6565 ext. 118 Josephine P. Tittsworth, ABD, LMSW, BSW, AA [email protected] Texas Transgender Nondiscrimination Summit www.sbchc.net P. O. Box 1095 Baytown, Texas 77522 832-514-0650 Cannon Flowers, Founder & Board Chair [email protected] Coalition for Aging, LGBT (DFW) www.txtns.org 3809 Parry Ave, Suite 305, Dallas, TX 75226 Gretchen Walton 214-577-7976 Breast Health Collaborative of Texas [email protected] 2990 Richmond Avenue, Suite 310 www.cfa.lgbt Houston, Texas 77098 713-777-3200 Sara Fernandez, president [email protected] Association for Family and Community www.Bhctexas.org Integrity, Inc. P.O. Box 667341 Katy Caldwell, Executive Director Houston, TX 77266 Legacy Community Health Center [email protected] 1415 California Street www.glbthomeless.org Houston, TX 77006 832-548-5000 [email protected] www.legacycommunityhealth.org 3 Joe C. Fuentes, Jr., MBA, Founder/Chief Rafael McDonnell, Communications & Advocacy Executive Officer Manager Houston Area Community Services, Inc. (HACS) Resource Center 2150 West 18th Street, Suite 300 - RM A 2701 Reagan St, Dallas, TX 75219 Houston, Texas 77008 214-528-0144 832-384-1389 [email protected] [email protected] www.myresourcecenter.org www.hacstxs.org Michel Muylle, Chairman of the Board Kelly Young, Chief Executive Officer Live Consortium AIDS Foundation Houston, Inc. PO Box 130897, Houston, TX 77219 6260 Westpark Dr. Suite 100 (713) 861-LIVE (5483) Houston, TX 77057 [email protected] [email protected] www.liveconsortium.org www.aidshelp.org Brandon Beck Chuck Smith, Executive Director Transgender Education Network of Texas Equality Texas & Equality Texas Foundation 3515B Longmire Drive #299, College Station, P O Box 2340, Austin, TX 78768 Texas 77845 512-474-5475 x1 830.832.6637 [email protected] [email protected] www.EqualityTexas.org [email protected] David Mack Henderson, President Esperanza Brown, EMBA, Director of Business Fairness Fort Worth, Inc. Development 3000 S. Hulen St., STE 124-246 Black Transmen Incorporated Fort Worth, TX 76109 3530 Forest Lane, Suite 38, Dallas, TX 75234 817-776-4555 (424) 255-8636 [email protected] [email protected] www.fairnessfortworth.org www.blacktrans.org Susan Fordice, President & CEO Mental Health America of Greater Houston 2211 Norfolk, Suite 810, Houston, TX 77098 713.520.3474 [email protected] www.mhahouston.org 4 .