Video 3: Overcoming roadblocks to transgender insurance coverage

♪ Hi, I’m Noah Lewis, Executive Director of Transcend Legal Transcend Legal is a national nonprofit organization focused on helping people access trans-related health care under insurance

We're trans-led and trans-run and we're the only trans legal organization dedicated to ending trans health exclusions Welcome to our third video in this series about how to get trans-related health care covered under insurance Thanks for all of the comments and questions we've received so far We're really excited that so many trans people are learning about their insurance rights and are interested in standing up for themselves If you haven't had a chance to watch the first two videos, please go check them out now

In the first video, we went over how to track down your particular insurance plan and figure out what it covers In the second video, we went over how to apply for coverage and know what your out of pocket costs will be In this video, we'll give you some examples of people who have successfully gotten insurance coverage for trans-related care We'll describe what happens during the appeals process, and we’ll also go over what it looks like if you want to challenge an explicit exclusion in an employer-based plan To kick things off, I want to introduce you to another colleague at Transcend Legal, Patricia Harrington

Hi, my name is Patricia I work with Noah and Charlie at Transcend Legal Prior to that I spent several years as the Intake Coordinator at the Transgender Legal Defense & Education Fund During that time I fielded many phone calls from trans people seeking assistance accessing trans health care and insurance coverage for that care One call I received really stood out

The caller was completely despondent, almost suicidal, because she felt that she could never afford to get the medically necessary treatment she needed I asked her if she had health insurance She said she had employer provided health insurance I asked her who her employer was and she said she worked for a major airline I knew that this particular airline provided health insurance with coverage for transgender health care

In fact this airline was known for generous health care coverage I told the caller that her employer-provided health insurance might cover her care I asked her to check with her human resources department and see what her options were The next day she called back a completely different person She had contacted her human resources department and learned that not only would her surgery be covered but the plan also provided a transportation allowance for travel to a surgery in another part of the country

 She was ecstatic and couldn't thank me enough In fact all I did was prompt her to take that first step and not assume that the situation was hopeless I’d like to encourage you not to assume that your health care will be denied Sometimes taking the first step is the most important thing you can do So I hope by now you’ve been able to get a copy of your plan booklet and your insurance company’s medical policy, and are ready to start trying to get the health care you deserve

 Not all insurance cases are going to be that easy If there is an exclusion in your plan, or your preauthorization or claim has been denied, you may need legal assistance to help you get the coverage that you needHi, I'm Charlie Arrowood, an attorney at Transcend Legal I help trans people appeal insurance denials Several months ago, a family was referred to us because their sixteen-year-old son's top surgery was denied

Their self-funded, employer-based health plan covered trans health care, but the insurance company's medical policy had a requirement that the person be at least eighteen years old to undergo surgery Just before the scheduled surgery date, he received a denial of preauthorization on the basis that he wasn't eighteen He was devastated, and his mother was concerned that he wouldn't be able to wait until his eighteenth birthday to have surgery We gathered his medical records and got additional letters of support from his providers We pulled together all of the medical evidence saying that top surgery in people under eighteen is the standard of care and is safe and effective

We also explained why it’s unlawful discrimination to deny this medically necessary treatment The insurance company denied the first level appeal As part of the first-level appeal, the insurance company had their own doctor engage in a peer-to-peer review with the surgeon in order to issue an opinion on whether the procedure was medically necessary But their doctor had never dealt with transgender patients at all, let alone a transgender adolescent They had offered no justification for why eighteen was the magic number, and we had clearly shown that it was not

We submitted a second-level appeal with some additional information, including a supporting letter from the main author of the most recent, most relevant study on the topic The day we were scheduled to do a phone hearing with the insurance company, they called to let us know our second level appeal was successful They'd reversed their decision based on the evidence we had submitted, and the young man's surgery would be covered! We work with people all across the country, so we aren't always able to meet people in person But in this case, a few days after we found out about that decision, we were able to meet the young man and his mom at the Philadelphia Trans Health Conference You could tell they both were finally able to breathe a sigh of relief

Most people will look at a medical policy that says you have to be eighteen and assume that's the end of the story But an insurance company's decision has to be based on current medical standards, and most of the written policies have outdated or just plain false requirements Many medical policies categorize all facial surgery and breast augmentation for trans women, and nipple reconstruction for trans men as "cosmetic" When insurance companies are denying claims unfairly, it is possible to put up a fight, and as this story demonstrates, those fights can be successful We can't guarantee success in every case, but if you just stop at the first potential roadblock, you definitely won't get coverage

So now we’re going to go over the appeals process and some pitfalls to watch out for First, you want to understand what type of appeals are available to you Your plan booklet will have a section explaining how to appeal a denial of coverage, and there should be information about it in the denial letter itself The exact procedure will differ depending on your type of plan and the insurance company, but generally, there will be one or two levels of “internal” appeal, meaning that the insurance company itself re-reviews the claim Then oftentimes an external appeal is possible

That means you submit the information to an independent review body that makes the decision, not the insurance company If you have Medicaid or Medicare, there is also a fair hearing process that you can go through Oftentimes internal appeals are not successful You are simply re-asking the insurance company to cover the procedure, and they are basing their decision on the same policy that led them to deny coverage in the first place If your plan has a trans exclusion or the insurance company deems your procedure “cosmetic,” then the insurance company has little incentive at this point to change their decision, but sometimes they do

So you'll re-submit the documentation you submitted in the first place, plus anything that may have been missing It’s also helpful to have your providers write letters specifically in support of the appeal When we at Transcend Legal assist people, we compile and submit extensive medical evidence about the medical necessity of the procedure at issue If your internal appeals are denied, you can move onto the external appeal if you have one available to you The external appeal does not always succeed, but it is more likely to

You will submit your evidence of medical necessity to an external, independent body that will assess whether or not the insurance company made the correct decision The external appeal can overturn a denial, and it is binding on the insurance company Next, it is important to be aware of the deadline to appeal a denial Make sure to check the deadlines for your plan because if you miss them, you may lose the opportunity to challenge a denial And if you have already paid out of pocket, there are also deadlines to file a claim, so look in your plan booklet to find out how quickly you must submit your claim

It’s important that your appeal is thorough and timely If you’ve already had surgery, you don’t want to mess up your appeals because you only have a certain number of them Additionally, if you don’t submit the proper information during the appeals process, then it’s hard to come back later and fix that By not doing the appeals process properly, you might be forfeiting your rights later on For most insurance companies, you can initiate an appeal simply by calling on the phone

You do NOT want to do this When you’re calling the insurance company to ask about a denial, be careful that you don’t inadvertently initiate an appeal If you initiate an appeal by phone, they may make a decision without you having provided any additional information That’s like throwing away an appeal Done properly and under the right circumstances, the internal and external appeal processes are the right remedies and will get you the coverage that you need

But if you have a self-funded employer-based plan or a Medicaid plan with an exclusion, you will probably need to enlist some outside help to succeed because the way to challenge those denials is usually through filing a charge of discrimination with the appropriate government agency, or by filing a lawsuit in court The case Charlie described at the beginning was an appeal with an insurance company Another type of case we work on is one where there is an explicit exclusion in a self-funded employer health plan  As we described in the first video, that's where the employer is responsible for the terms of the health plan and has the power to remove the exclusion In order to assert your rights under the plan, it does mean that you have to explain to your employer that they are engaging in unfair discrimination

While it is unlawful to fire someone for reporting discrimination, retaliation is a concern, so you might want to speak with an attorney before approaching your employer about this issue But it is generally a good idea to let the human resources department know that you are being denied health care under the plan and ask them to remove the exclusion You would be surprised at the number of employers who will take action once this issue is brought to their attention Someone who filled out our survey on issues people are having accessing trans health care under insurance wrote that there was an exclusion in his self-funded employer-based plan He wrote, “I am desperate to have top surgery because the dysphoria is so bad

” “How am I supposed to figure all of this out when there are days I can barely get out of bed in the morning because my depression just gets worse” Because of the urgency in his request, I reached out to him right away I explained that the exclusion was unlawful

He was prepared to enlist our help, but he had not yet approached his employer directly, so he wanted to do that first Just six weeks later, he wrote back saying that shortly after we spoke, he decided to email his supervisor The supervisor put him in touch with right person who said she would do some research and get back to him Eventually she called him to let him know that they would be removing the exclusion effective January first But if you've already approached human resources and they say they're not going to get rid of the exclusion, then your next step might be getting an attorney to write a letter on your behalf

This is known as a demand letter The letter would explain why it's unlawful for them to have an exclusion In many instances, this letter alone is sufficient to get the employer to change the policy or at the very least pay for your surgery If the letter doesn't work, the next step would be to file a charge of discrimination with the federal Equal Employment Opportunity Commission or EEOC In rare cases, you might actually have to file a lawsuit before the employer will agree to change the policy

But in our experience and the experience of many other organizations, most of these cases are resolved without going to court So now maybe you’re thinking that this sounds like a lot of work and you’re wondering if it would work for you Without looking at your specific situation, we’re not able to say what might work for you But there is one thing we can say with certainty: if you don’t investigate and try to get coverage you’re definitely not going to get coverage! So, what do you have to lose? When approaching insurance issues, you want to approach the situation optimistically, but realistically These are for-profit companies that make money by collecting premiums and not paying out claims

These companies generally don’t do the right thing simply because you ask them once It’s a process, and it takes time In many situations getting a denial is to be expected It’s just a bump in in the road on your way to getting your surgery I spend every day dealing with insurance companies and employers that have exclusions

You wouldn’t believe the kinds of things insurance companies try to pull Whether it’s intentional or just incompetence, they definitely don’t make it easy to get coverage The State of California, for example, fined health insurer Health Net $200,000 for violating nondiscrimination laws by repeatedly denying coverage to patients who sought trans-related care Insurance companies rely on denying claims and knowing that many people simply wouldn’t stand up for themselves and fight the denials Don’t be one of those people who just lets a big corporation or government treat you unfairly

I cannot guarantee it will work for everyone or you, but I wouldn’t be devoting my life right now to battling insurance companies if I weren’t seeing results Now, we’ve explained the basics of how to know what your plan covers, how to apply for coverage, and what to do if you’re denied Hopefully for many people the information we’ve already given you will be enough to get your coverage But at this point you may have done the research about your plan and know that you are not able to move forward without some legal assistance Or you may know what steps you need to take, but want to make sure you’re doing them correctly

Or you just might not want the hassle of interacting with an insurance company, and want someone else to handle if for you It's difficult to find law firms to work on these cases pro bono because large law firms tend to represent insurance companies and these firms can't sue their own clients And smaller law firms generally aren't interested in these cases because they are not profitable and they don't have the relevant expertise in trans issues to take them on  Although I've been working on trans health care issues for twelve years, I founded Transcend Legal less than a year ago It's still a small organization and there are only so many cases we can take on

There is little grant money available for this work, so we rely almost exclusively on legal fees and individual donors to fund this work So, while we can't help most people for free, our fees are a lot cheaper than paying out of pocket for surgery! If you think you need legal assistance, stay tuned for our next video where you can find out how Transcend Legal might be able to help YOU get the health care that you need Thanks for watching If you found these stories inspiring, please share this video with someone you know who may need coverage so that they can take the next step towards getting the health care that they deserve ♪

Source: Youtube

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