Washington state Attorney General Bob Ferguson has warned insurance companies that they should "eliminate invisible barriers to gender-affirming care."

"We urge you to review and ensure that your policies and medical guidelines interpret medical necessity for gender-affirming care as broadly as possible to ensure the well-being of each patient," Ferguson said in April 28 letters to 12 insurance companies.

Ferguson warned the companies that Washington State Insurance Commissioner Mike Kreidler took administrative action against at least one insurance provider for failing to cover breast augmentation services following a medically necessary mastectomy.

"Even so," Ferguson continued, "the Attorney General's Office continues to receive complaints of barriers to receiving the medically necessary gender-affirming care that every Washingtonian is entitled to."

Washington state law requires coverage of medically necessary gender-affirmation services, and Ferguson noted that Aetna — a major insurance company — will cover gender-affirming augmentation for transfeminine members in most of its commercially available health plans.

"This change followed conversations with the Transgender Legal Defense and Education Fund and transgender women who were denied medically necessary care," Ferguson noted.

"This change by Aetna at a national level is an important step toward equity in the provision of health care."

According to Ferguson, many health insurers have excluded breast augmentation surgery and other essential treatments — like facial electrolysis — as cosmetic, rather than medically necessary.

"[W]e recommend you review claims denied as 'cosmetic' and whether the medical procedure was prescribed to a transgender, nonbinary, or gender-diverse person as medically necessary," the attorney general told the insurance companies.

"These denials are harmful to transgender Washingtonians, and it is disproportionately harmful to transgender Black, Indigenous, and people of color communities. Adults who identify as Black, Latinx, or of another race or ethnicity are more likely than white adults to identify as transgender.

"In a 2015 report by the National Center for Transgender Equality, one-third of these communities, as well as transgender people with disabilities, reported negative experiences when they saw a health care provider, including being refused treatment or having to teach the provider about transgender people in order to get appropriate care."

Ferguson's letter was co-signed by Entre Hermanos, Equal Rights Washington, the Gender Justice League, Gay City, the GSBA, Legal Voice, the QLaw Association, the QLaw Foundation, and the Rainbow Center.

It was sent to Bordeaux Anthem, Berge CHPW, Fathi-Molina, Daniels-United Healthcare, Johnson-Coordinated Care, Broussard-Humana, Blackledge-Mutual of Omaha, Hochman-Providence, Cordani-Cigna, Mullaney-Kaiser, Verity-Regence Blue Shield, and Roe-Premera Blue Cross insurance companies.