Alright, I'm doing this! I've been watching this thread for awhile since I've decided I'm getting FFS, but most importantly, I'm going to get insurance to pay for it one way or another. I'm very patient, but also very committed. It's an uphill battle for sure, but one I hope will help to set a precedent.
Here's my current details:
State: California
Insurer: Anthem Blue Cross
Plan: Prudent Buyer Classic PPO 250-20/10 (modified)
Here's the relevant section of our Anthem policy regarding covered transgender related procedures:
Quote
Transgender Services. Services and supplies provided in connection with gender transition when you have been diagnosed with gender identity disorder or gender dysphoria by a physician. This coverage is provided according to the terms and conditions of the plan that apply to all other covered medical conditions, including medical necessity requirements, utilization management, and exclusions for cosmetic services. Coverage includes, but is not limited to, medically necessary services related to gender transition such as transgender surgery, hormone therapy, psychotherapy, and vocal training.
Coverage is provided for specific services according to plan benefits that apply to that type of service generally, if the plan includes coverage for the service in question. If a specific coverage is not included, the service will not be covered. For example, transgender surgery would be covered on the same basis as any other covered, medically necessary surgery; hormone therapy would be covered under the plan's prescription drug benefits (if such benefits are included).
Services that are excluded on the basis that they are cosmetic include, but are not limited to, liposuction, facial bone reconstruction, voice modification surgery, breast implants, and hair removal. Transgender services are subject to prior authorization in order for coverage to be provided. Please refer to UTILIZATION REVIEW PROGRAM for information on how to obtain the proper reviews.
It's great in that it covers GRS (which I'm getting in 3 days, yippee!) but given that it specifically excludes FFS and other procedures, I know I'm in for quite a bit of denials and subsequent appeals.
What I've done so far:
- Contacted our benefits provider regarding exclusions
- Had consultations with a couple different FFS surgeons
Next up:
- Make an appointment with my GP
- Make an appointment with my therapist
- Gather documentation, specifically official documents that state this is medically necessary as well as the relevant insurance codes (waiting on those from Dr. Z)
I believe the next steps after that would be to submit a pre-authorisation request, await the inevitable denial, then appeal the
>-bleeped-< out of it, all the way up to the state board if necessary. Sound about right?
Of note, my company also offers Kaiser, which seems more friendly to non-GRS transgender related procedures as they mention that they may be covered if determined medically necessary, unlike Anthem's more hard line exclusion. Here's what I found after speaking to our benefits provider.
Quote
Transgender surgery is covered as a base benefit for all fully insured DHMO/HMO members with a diagnosis of gender dysphoria. Covered transgender surgical services include genital surgery and mastectomy with chest reconstruction and must be pre-authorized by the Medical Group. Services that are "cosmetic" (i.e., intended primarily to change or maintain appearance) are generally excluded from coverage for all members, unless the services are determined by a Plan physician to be covered as medically necessary reconstructive surgery.
Medical Services to treat gender dysphoria, such as mental health services and hormone therapy, are covered under the base medical benefit or supplemental drug benefit when determined by a Plan physician to be medically necessary.
As of 2016, many Kaiser plans have been offering FFS procedures through a couple local surgeons. Perhaps it makes more sense to wait until open enrolment next year to switch? I'm not sure of the answer yet, nor do I know if we'll even offer Kaiser in the new year, but I do feel it is in my best interests to move forward with Anthem as much as possible. Any progress is good progress!
