Video 2: How do I apply for transgender insurance coverage?


♪ Hi, I’m Noah Lewis, Executive Director of Transcend Legal Welcome to our second video in this series about how to get trans-related health care covered under insurance

Thank you for all of the comments and questions, we'll be answering some of them in this video and the next one If you haven't had a chance to watch the first video, definitely go back and check it out But to recap, I discussed how it's time to stop paying out of pocket for trans-related health care It's time to stop going without the health care that you need If you're paying insurance premiums, you deserve to be able to access health care under your plan

There are legal protections in place, and trans people have the opportunity to collectively stand up and get the health care that we deserve In law school, my student health insurance plan excluded trans-related health care Thinking about challenging that exclusion was exhausting But one day I decided I wasn’t going to take it anymore, and I chose to stand up for myself It was a lot of work and it was emotionally draining, but eventually they changed the policy

That fight was hard in part because I didn’t have anyone to help me That’s why I founded Transcend Legal I know how life-changing hormones and surgery were for me, so I work full-time helping other trans people to get the health care that you need to transform your life Thankfully, I don’t have to work alone anymore One of my colleagues at Transcend Legal is Charlie Arrowood, and I want to introduce you to him now

Hi, my name is Charlie Arrowood, and I'm an attorney with Transcend Legal I've always had weird feelings about my gender, but I didn't think of myself as trans until a few years ago I socially transitioned about 15 years ago—well before identifying as trans—but I never bothered doing anything to medically transition because I was overwhelmed by the thought of finding the right providers and getting coverage Fortunately, last year I met Noah and started working with Transcend Legal I was able to learn the ins and outs of trans insurance coverage

It took lots of phone calls and paperwork and lots of help from my wife and her employer, but I was ultimately able to get full coverage for both hormones and surgery, despite not identifying as a binary trans man Having surgery was hugely meaningful to me I can stand up straight My clothes fit And I don't panic about getting in the shower anymore

It was literally and figuratively a huge weight off my chest, and it never would have happened if it weren’t covered by insurance But you are not alone if you are confused by how to get surgery covered I'm an attorney and until I started handling it for other people, I didn't understand even the basics of insurance, let alone any of this trans stuff Our goal here is to explain the basics to you so you know your options, but you may need individualized input or assistance from someone who specializes in trans insurance issues if you’re still having a hard time getting coverage In this video we’re going to answer the question of how to go about applying for insurance coverage

We’re not going to be giving you any legal advice about what you personally should do, but we will be giving you general information about the process We’re going to start by telling you about one more document you need to get in order to understand what your plan will cover and what you need to do to get that coverage In the first video, I explained how to find out what your particular insurance plan covers I explained how to get a copy of your plan booklet and what to look for once you get it Hopefully by now you’ve been able to get a copy of your plan booklet, or at least have requested it

But there is a second document you need that I briefly mentioned in the first video This is your insurance company’s medical policy on treatments for gender dysphoria It may be called things such as a Medical Coverage Policy, a Clinical Policy Bulletin, or Clinical Criteria We have compiled a list of over sixty such policies under the resources section of our website at transcendlegalorg

So that should be your first stop for trying to locate the policy If it’s not there, you can call the number on the back of your insurance card and ask them to send it to you, though not all companies have a specific policy on transgender care What a medical policy is, is the insurance company's guidelines for what kinds of evidence it wants to see before it will pay a claim Most of these policies have onerous requirements that are not in line with the standards of care of the World Professional Association for Transgender Health or WPATH The policy provides you a roadmap of the information that you need to give to the insurance company

This is generally one or two letters from a therapist, and these policies outline what should be in those letters There may also be other requirements such as having persistent gender dysphoria, being on hormones for a year or being at least 18 years old to have surgery If you do not meet the requirements in the policy, that doesn’t mean that you have no hope of getting coverage – you’ll just have to challenge the denial if you are denied based on that policy So when you are asking your mental health provider for a letter, give them a copy of the medical policy and tell them to make sure to explain how you meet all of the insurance company’s criteria If you don’t meet the criteria, have the therapist explain why the criteria shouldn’t apply to you

While many insurance companies recognize, for example, that being on testosterone is not required before undergoing top surgery, some still may have this listed as a requirement In addition to your therapist, you can also get letters from your hormone doctor and your surgeon in support of the surgery Ask your provider to start the letter by listing their own credentials including their education, experience working with trans people, and any relevant training, publications, or professional memberships Some providers write minimal letters because they don’t want to pathologize trans people But that isn’t helpful when it comes to proving that the treatment you need is medically necessary

While there’s nothing wrong with being trans, trans people who are seeking access to medical treatment know that there is definitely something about their body that needs to be changed in order to alleviate their gender dysphoria We’re not yet at the point where trans coverage is automatic, particularly for things like facial surgery and breast augmentation So the therapist letter shouldn’t just say that the person is ready for surgery and understands the risks of the procedure They need to describe how the person has gender dysphoria and list the specific challenges the person faces because of it—such as being depressed, being afraid to leave the house, or needing to wear a binder The letter should explain that they need to change their sex characteristics in order to alleviate their gender dysphoria

People aren’t having surgery because it’s a lifestyle choice This is medical treatment for a particular diagnosis, and provider letters need to make that clear Some people have asked if it’s possible to forgo getting a therapist letter Most insurance company medical policies don’t require therapist letters for hormones, except for puberty suppression If you go to a provider who uses an informed consent model, then it’s possible to get hormones without a therapist letter

But for surgery, one therapist letter for top surgery and two letters for bottom surgery is what the WPATH Standards of Care currently recommend, and what most surgeons follow Because therapist letters are still the standard of care, there is no strong basis to challenge an insurance company requirement for these letters So once you know the insurance company’s criteria and are working on getting your therapist letter, you’ll want to actually apply for coverage and see what the insurance company says This process is called getting preauthorization or prior authorization In Medicare Advantage plans, it’s called an “organization determination

” You can do this regardless of whether or not your plan excludes trans-related health care And if you’ve already had surgery and paid out of pocket, then you would go ahead and submit a claim for reimbursement Sometimes the insurance company may give you a hard time or deny full benefits if you did not apply for preauthorization, so it’s important to do that even if you plan to pay out of pocket Now you could just call the insurance company and ask if they cover it, but that's not really going to give you a definitive answer The people who answer the phones are not given the best training, so they may just tell you it’s excluded, or worse, tell you it’s covered when it’s really not

But even if they tell you it’s covered in general, that doesn’t mean it will be covered for you specifically So that’s why it’s important to get a determination about your particular situation Applying for preauthorization results in a formal decision can be appealed if it’s denied Ideally, you want to have your surgeon apply for preauthorization So you want to find a surgeon and have a consultation

When choosing a surgeon, find out if the surgeon accepts insurance or not If they do accept insurance, determine if they’re in network or out of network for your plan To do that, go to your insurance company’s website, and search in their “find a doctor” section Also search for the facility where you’ll have your surgery to make sure that’s also in network If the provider is out of network, find out if they will give you the proper paperwork to make it easier for you to be reimbursed by your insurance company

Some of the most popular surgeons won’t help with insurance paperwork at all, which makes the process more of a hassle than it should be Most surgeons now have a person who handles working with insurance companies That definitely makes things easier on you, so take that into consideration when choosing a surgeon If you’re not able to pay out of pocket and be reimbursed, there’s something called a Single Case Agreement that a nonparticipating provider can enter into with the insurance company So, if you know the doctor or surgeon you want to go to and you've already had a consultation, have that provider submit a preauthorization request

If your surgeon does not accept insurance or is unwilling to submit the preauthorization request, you can ask your primary care provider to do it, or you can do it yourself And what happens if you do get coverage? How much will you have to pay out of pocket? This is where you’ll want to look at the Summary of Benefits and Coverage chart for your plan First, find out what the deductible will be The deductible is the amount you must pay out of pocket before the insurance plan will even start paying benefits There may be separate deductibles for in-network and out-of-network care

So even if you've already met your deductible for in-network care, but you're choosing an out-of-network surgeon, you're going to have to pay the full out-of-network deductible before coverage kicks in The good news about a deductible is that once it's met, it's met for all of the care you receive later on in that same plan year Note that the plan year might not run from January to December The coverage period will be listed at the top of the Summary of Benefits so you'll know on what date the deductible you've already paid resets to zero So, let's walk through an example

If your surgery costs ten thousand dollars and you have a $3,000 deductible, you'd be paying $3,000 out of pocket if you have not already contributed anything towards your deductible But then what happens? Is the remaining $7,000 fully covered? Probably not This is due to copays or co-insurance A copay is a fixed amount you must pay for certain services So, your plan may have a $75 copay for outpatient surgery

Or instead of a copay, you may see that it says "co-insurance" such as 20% co-insurance for in-network benefits and 40% co-insurance for out-of-network services "Co-insurance" is a clever insurance industry term meaning that you yourself are partly responsible for paying for the service It means you pay 20% or 40% of the cost While it's rare, you should ask your benefits administrator or HR if your employer has any programs to help cover co-pays and co-insurance costs My insurance covered my surgery, but I still would've had to pay that portion

Because my wife's employer was enrolled in a special plan that paid the co-insurance, we ended up paying nothing So, continuing on from our earlier example, of the remaining $7,000 after the deductible was paid, you would owe 20% or $1,400 if the surgeon and the facility were in-network and $2,800 if they were out-of-network Note that you can go to an out-of-network surgeon who performs the surgery at an in-network facility or vice versa So, this is all starting to add up With the deductible and coinsurance combined, you're looking at $4,400 for in-network or $5,800 for out of network

 This is where the out-of-pocket limit comes in The out-of-pocket limit is the maximum you will pay out of pocket in a given plan year So, in this example, the out-of-pocket limit is $3,500 for in-network and $7,000 for out of network So that $4,400 figure? The insurance company can't collect that from you The most you would pay is $3,500 if your provider and the facility were both in-network

But if your provider and the facility were out of network, you'd still be stuck paying the $5,800 So, you can see how important it is to find a surgeon who is in network It can mean thousands of dollars difference in the cost of your surgery This is why if you can't find a qualified in-network surgeon you'll want to ask for your provider to be considered in-network for billing Your in-network primary care provider can put in a request to the insurance company, and ideally you'll want to have the letter from the surgeon as well explaining the specialized nature of the care

The same process would apply if you have no out of network coverage at all and need to go to an out of network surgeon If you plan pay-out-of-pocket up front and seek to be reimbursed, there is another thing to be aware of The insurance company doesn't have to reimburse you the full amount In addition to the usual deductible and co-insurance, if your surgeon has charged an unusually high rate, the insurance company doesn't have to pay the full amount They only have to pay an amount that is usual, customary and reasonable

Those numbers aren't well-defined for trans care, but you can try to find out from your insurance company beforehand what their allowed amount will be, and you might be able to challenge it if their amount is unreasonable There’s one last thing we want to flag Sometimes when employers with self-funded plans remove trans exclusions and add explicit coverage, they’re afraid that all of their employees are suddenly going want to transition So, they impose a special lifetime cap on trans health care, often $75,000 or less However, given that no other type of care has a lifetime cap, such limitations are unlawful discrimination and can be challenged

So, to recap, in this video we’ve explained how to get your insurance company’s medical policy to understand the information you need to provide in order for your care to be covered We explained what makes a good therapist letter, how to apply for preauthorization, and how to calculate your out-of-pocket costs But what happens if the insurance company denies your preauthorization request or post-service claim? This is not the end! In fact, now you can appeal the decision Our next video will cover your appeal rights and what to do if you are denied I hate to see any trans person with insurance going without surgery or trying to raise money so that they can pay out of pocket

Since trans people have been getting denied coverage for so long, I know that people are skeptical about getting insurance coverage and think it won’t work for them If that’s the case for you, then stay tuned for our next video We’ll be sharing some stories of people who have successfully gotten coverage and what that process looks like Hopefully you will see that this is possible for you as well Please scroll down and leave a comment so that we can know if these videos are useful or not

And please share this video with your friends Together we can make sure that all trans people get the health care that they need—with insurance Thanks for taking part ♪

Source: Youtube


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