Video 1: Does my insurance plan cover transgender care?


♪ Hi, I'm Noah Lewis, and I'm going to share with you a roadmap for getting trans-related health care — including surgery — covered under insurance If you’re saving up for surgery, or have given up hope of saving up for surgery, then this video series is for you

If you have surgery scheduled and are about to spend $7,000 or maybe $30,000 out of pocket, then you'll want to pay attention as well And if you’ve already paid out of pocket, there’s a chance you might be able to get reimbursed I transitioned in 2005, when I was a student at Harvard Law School I was the first openly trans student at Harvard Law, and I was unable to access surgery because the student health plan had an explicit exclusion for sex transformations So I investigated and wrote a paper on why it was unlawful for Harvard to exclude transgender health care

I advocated with Harvard, and they eventually removed the exclusions from both its student and staff plans I know the dramatic difference that hormones and surgery made in my life, and I know not everyone has access to a law degree That is why I founded Transcend Legal Transcend Legal helps people access trans-related health care under insurance Our goal is to eliminate all trans health insurance exclusions in the United States

When I was a law student, it was still quite rare for companies and schools to cover trans-related care But that is no longer the case Now is the best time in history for people in the US to access trans-related health care through their insurance plan

Trans people have been paying out of pocket for health care for so long that many people still assume that this is the best or only way they will be able to get the hormones, surgery or puberty suppression treatment that they need This is particularly true if the surgery needed is facial surgery or breast augmentation The fact of the matter is, if you have insurance, there is likely the possibility that you could have surgery and have it be paid for by your insurance We believe that no one in the US

who has insurance should have to pay for trans health care out of pocket So that's our first take-home message Generally your insurance plan should cover your surgery, and if it doesn't, there are many legal protections available to help you challenge that denial We'll be going over your rights and the legal remedies available later on in this video series Some people prefer to just pay out of pocket rather than asserting their rights

It can seem daunting to take on insurance companies and fight for equitable coverage But you don't have to do it alone It's important to recognize that this is a collective effort Trans people coming together as a community and standing up to insurance companies is the only thing that will bring about change to ensure that all trans people of all income levels can get the health care that they need So this isn't just about getting your surgery covered

It's also about getting your surgery covered so that the next person doesn't have to have that same fight We as trans people have all benefitted from the trans people who came before us and were open about who they were even in the face of discrimination, violence, and great personal loss Those of us who have benefitted from our trans forebears can draw on their strength to stand up and fight for equal access to health care Trans people pay the same premiums and taxes as everyone else, but receive unequal benefits in return It's time for that to end

So you're probably wondering, “How can I know if my insurance plan will cover my surgery?” This is not a simple question, but we're going to give you the tools you need to find that out So, a lot of people look at their insurance card and they think, "Oh, I have Aetna" or "I have Blue Cross," and they do a Google search for "Aetna gender reassignment surgery" and they find the medical policy for that insurance company, and they think it's covered But that's not the whole story That's only the generic policy for how that insurance company decides whether they are going to cover a surgery for a given individual But what you need to know is what your specific plan says about trans healthcare

In order to do that, you need to get a hold of your plan booklet This has a lot of different names – it might be called a Certificate of Coverage, a Summary Plan Description, a Member Handbook, a Benefits Certificate, a Certificate of Insurance, and so on So we're going to dive right in and give you a homework assignment To get the most out of this video series, you're going to need to find out what kind of insurance plan you have To do that, you're going to need to get a hold of your plan booklet

This should have been given to you when you first got the plan It may have been mailed to you, or if it's an employer-based plan, given to you when you started the job If you have a benefits or insurance website that you can login to, you can start there Now you're going to see a lot of other documents that are NOT your plan booklet You're going to see something called a Summary of Benefits

It's a little chart that lists things like deductibles and copays for various types of health care This is NOT your plan booklet What this document is useful for, however, is seeing how much you will have to pay out-of-pocket We'll talk about that more later on, but let's not be distracted in our quest for your plan booklet Particularly if you're on an employer's website, you might find a PDF that describes various benefits that the company offers

If you find a document like this, here are some clues that it's probably NOT your plan booklet: First, if it has a lot of pictures of smiling people throughout it, this is most likely NOT your plan booklet No one is smiling when they read their plan booklet Secondly, if it's describing other types of benefits such as disability benefits, pre-paid legal services or life insurance, it's less likely to be your plan booklet Third, search for the exclusions and limitations section You may find language telling you that the exclusions can be found elsewhere

If you cannot find an exclusion or limitation section, it is definitely NOT your plan booklet So if you're lucky, you'll be able to find your actual plan booklet as a PDF It's a big document, generally 70 pages or more And if you don't have an electronic copy, you're looking for an actual paper booklet If you weren't able to find it online, you can call the number on the back of your card and ask them to send it to you

Make sure you explain to them that you want the big document that lists all of the exclusions, not just the summary of benefits chart If you have a plan through your employer or your parents' or partner's employer, you can contact HR or the benefits department It's best to do this by email, and you should ask for what’s known as the Summary Plan Description By law, most employers are required to provide this document to you if you request it in writing If you already have your plan booklet, you’ll want to immediately go to the exclusions and limitations section and see if they have an explicit exclusion for transgender-related health care

It might say something like “transsexual surgery,” ”sex transformations" or "gender reassignment surgery" or "sex change" If you have a PDF you can search for the words sex or gender and that will usually bring it up Occasionally you might be lucky and find that there is explicit coverage listed for trans-related care Sometimes only certain kinds of care are covered and others excluded, and we’ll talk about that more later If there is an explicit exclusion, that does not necessarily mean you cannot get coverage

There are many reasons why the exclusion might not be valid For one thing, the plan booklet might simply be out of date Insurance companies and employers don't always keep their plans up to date Many plans removed their exclusions in January of 2017 in response to nondiscrimination regulations issued under the Affordable Care Act or Obamacare The second reason the exclusion might not be valid is that your insurance plan might be regulated by one of the many states whose insurance departments have issued guidelines or regulations saying that there cannot be categorical exclusions for all trans-related care

Note that if this is an employer-based plan, the state where the insurance plan was issued might be different from the state where you live, and it's the state where the plan was issued that governs – not the state where you live The third reason why the exclusion might not be valid is because your plan might not be "insurance" at all If you have health care coverage through an employer, it's going to be one of two things: it's either going to be an insurance plan or a self-funded health plan An insurance plan is where the employer buys a group insurance plan from an insurance company The insurance company is responsible for paying all of the claims and administering the plan

In a self-funded plan, the employer sets aside a big pool of money to which employees and employers contribute and that money is used to pay out the claims The confusing part is that the employer generally hires an insurance company like Cigna or UnitedHealthcare to administer the plan and that's the name you're going to see on your insurance card In a self-funded plan, the employer is ultimately responsible for the terms of the plan The way this works in practice, however, is that insurance companies offer set plans to employers, and generally, that's the source of these explicit trans exclusions Many employers never sat down and decided to exclude trans health care

But the fact that your employer is responsible for the exclusion means you can ask them to remove it Many of you may be confused and wondering how it can be the case that you can live in a state such as NY that has an insurance bulletin prohibiting exclusions, and work for a NY-based employer, and yet, your employer has told you there's an exclusion that they're not getting rid of The reason for this is a federal law called ERISA – the Employee Retirement Income Security Act That governs employer-based health plans If you work for a private employer and you have a self-funded plan, ERISA overrides state law

One thing ERISA does is allow large employers that operate in multiple states to have one employee health plan for all of its employees regardless of what state they're in So, ERISA says that state insurance law and state nondiscrimination laws don't apply if it's a self-funded plan If your plan is insured, however, state insurance law still applies The way to know which state’s law applies is by looking at your plan booklet and seeing what state the plan was issued in The remedies that are available to you if there's an exclusion in your plan differ depending on whether it's insured or self-funded

So, you might be wondering, "how can I tell if my plan is self-funded or insured?" Sometimes it says so right in the plan booklet that this is a self-funded, non-insured plan Easy Otherwise, it requires more detective work and you definitely want to consult with an expert If it's a self-funded plan, it's required to have a page that lists the plan administrator That page will provide information about if the insurance company is just the claims administrator or if they are acting as an insurer

If it's an insurance plan, oftentimes there will be a group policy number at the beginning of the document You can also ask your benefits coordinator which kind of plan it is So after you've completed those three steps 1) Getting a hold of your plan booklet 2) Looking for an explicit exclusion 3) Determining whether it's self-funded or insured you're well on your way to knowing what YOUR health plan covers and what legal rights and remedies are going to apply to your situation In our next video we're going to discuss how to access care under your plan and what steps to take if you are denied Thanks for watching and do us a favor, scroll down, leave a comment

Ask a question Let us know if this was helpful or not And please share this video with your friends so that we as a community can move forward and eliminate trans health exclusions ♪

Source: Youtube


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