Colorado this fall began holding public hearings on proposed policy to cover transgender-related surgeries for people with Medicaid, government-sponsored insurance for needy and disabled Coloradans. The next hearing, scheduled for Feb. 16, will focus on transition-related surgeries. The process could take more than a year.

Medical guidelines regarding transgender care have changed in the last few years, with the American Medical Association and the American Psychological Association saying hormones and surgeries are the recommended course for patients with gender dysphoria.

Transgender health care A survey of transgender people published in 2011 found that about 20 percent were uninsured. Below is a breakdown of their insurance type and where they got care.

Times have changed and the state Medicaid program “has a responsibility” to evolve, said Judy Zerzan, chief medical officer for the state agency that runs the Medicaid program in Colorado.

“The world and the evidence and the practice of medicine evolve,” Zerzan said. “We think we have a responsibility to cover it when it’s medically necessary.”

The federal government prohibited Medicare and Medicaid from covering transgender-related surgery until 2014. The ban was lifted for Medicare, which provides health insurance for older Americans, but there was no universal policy change for Medicaid, which is administered by states.

Eight states changed policy in recent months to cover transition-related surgeries, but Colorado was not among them. An ongoing federal review requested by the Obama administration this fall could trump Colorado’s process if it requires all 50 states to cover transgender-related surgeries through Medicaid.

In September, the administration proposed a new anti-discrimination provision that could require doctors and hospitals to allow patients to use the bathroom of their gender identity as well as bar insurance companies from excluding transgender surgeries and therapy. The Affordable Care Act prohibits sex discrimination, but new rules would clarify that gender identity also is protected.

Colorado is among 13 states that prohibit insurance companies from blanket exclusions against transgender-related care, but the law does not mandate coverage of gender reassignment surgeries. The state Division of Insurance in 2013 said companies cannot charge transgender people higher premiums, consider transgender status a pre-existing condition to deny coverage or limit coverage for “medically necessary services” if the same service or surgery is provided to someone who is not transgender.

That means if a company covers hormone replacement therapy for other reasons, it should cover it for transgender people. But the law gets opaque regarding surgeries. If an insurer covers mastectomies for breast cancer patients, does it have to cover them for transgender people who want their breasts removed or augmented? And if a company covers a hysterectomy or genital surgery for a car accident victim or someone born with a genital anomaly, must it cover that for a transgender person?

“That’s where we are kind of stuck at this point,” said Matt Mortier, the insurance division’s director of compliance. “We would like some more concrete federal guidance.”