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Federal Judge Says State Not Obligated to Pay for Sex-Change Surgery
New York Law Journal
July 28, 2009
New York state is not obligated to pay for gender reassignment surgery for a Medicaid recipient, even though it provided coverage for individual procedures that are necessary preliminaries to the change, a federal judge in Buffalo has determined.
Western District of New York Judge Charles J. Siragusa in Rochester ruled that Morgana Ravenwood's constitutional rights under the 14th Amendment were not violated by the denial of coverage.
He also refused to order state Health Commissioner Richard F. Daines to rescind 18 N.Y.C.R.R. §505.2(l), the 1998 law prohibiting state Medicaid funding for "care," "services" or "drugs" related to gender reassignment surgery.
Ravenwood, an HIV-positive Rochester resident whose income is limited to Supplemental Security Income and food stamps, argued that diagnosis of a recipient's medical condition and the course of covered treatments prescribed for the patient cannot be linked under state Medicaid laws to rules drawn by Congress in federal Medicaid statutes.
"Plaintiff claims that, since Congress did not clearly state that treatment should be limited to diagnosis, then all treatments must be available for all diagnoses," Siragusa wrote in Ravenwood v. Daines, 6:06-cv-06355. "Plaintiff's contention, however, ignores an underlying assumption of medicine: that treatment is limited to diagnosis. The Court declines to take Plaintiff's expansive view of treatment."
Ravenwood produced declarations from her physicians that electrolysis and gender reassignment surgery are medically necessary to alleviate the suffering she has experienced since 1967 when, at age 5, she was diagnosed with a gender identity disorder.
Though born male, Ravenwood has identified as a female since 1967, according to Siragusa's ruling. She assumed the name Morgana Ravenwood in 2001.
Starting in 1998, the state's Medicaid program paid for hormonal treatment, voice therapy, water pills, medication and mental health care associated with her conflicted gender issues.
But it has refused to pay for transsexual surgery since 2003.
Ravenwood argued that she is entitled to coverage for the more advanced medical procedures entailed in a sex change operation, such as orchiectomy, the removal of testicles, because that surgery would be covered under federal Medicaid laws if deemed medically necessary for conditions such as cancer.
Female breast construction surgery should also be covered, Ravenwood contended, because it is covered under Medicaid for recipients who have undergone mastectomies.
Unlike New York state law, federal statutes are silent on Medicaid eligibility for coverage of the sequence of treatments and surgeries needed for gender reassignment.
Siragusa held that his ruling in Ravenwood's case is consistent with the equal application of Medicaid benefits enunciated under Rodriguez v. City of New York, 197 F.3d 611 (2d Cir. 1999), and with a Southern District ruling last year upholding New York's denial of coverage for gender reassignment in Casillas v. Daines, 580 F. Supp. 2d 235 (S.D.N.Y. 2008).
Siragusa also rejected Ravenwood's claim that her constitutional equal protection rights were violated by denial of coverage for a sex-change operation. She failed to demonstrate that the state's policy of excluding coverage lacked any "rational basis," the judge held.
The judge said he was also not persuaded by Ravenwood's argument that the state Legislature's failure to review 18 N.Y.C.R.R. §505.2(l) since 1998 compelled the constitutional-mandated rescinding of the statute.
"The mere passage of time is not a sufficient reason to find the law fails rational basis review," he wrote.
Medicaid provides for two kinds of benefit payments: to those found "categorically needy," such as the destitute elderly and the children of poor families, and those found "medically needy." Medical proof must be presented before beneficiaries can establish eligibility for medical need.
Alecia Elston of Segar & Sciortino in Rochester represented Ravenwood pro bono. She said Monday that the state had assumed a greater obligation to Ravenwood than it had to the plaintiff in Casillas because it funded coverage for several preliminary stages of the sex-reassignment process for Ravenwood. The state funded only hormone therapy for the plaintiff in Casillas.
"They took her [Ravenwood] all the way and then they said, 'No,'" Elston said. "We had statements from her doctors saying she wants to commit suicide. This is a mental health issue on top of a physical one."
