Decline insurance from work; buy my own?

[sarahbear]

My work insurance isn't great and doesn't have an option for transgender surgery. I'm wondering if I were to decline that and buy it on my own would it be possible to transgender surgery covered? I checked out the health insurance marketplace here in my state but it's not clear whether it would be covered by even the best plans and I'm not sure exactly how to find that out. Besides that I think it would be months before I would be able to opt out of my insurance but not 100% sure how that would work either. If I try to buy without going for an individual plan (pre-packaged in the marketplace) would it be really expensive? Any advice is appreciated.

[piglet smith]

If you currently have insurance, whether it covers trans stuff or not, you're better off keeping it for now. You really can't be sure what you really get in the marketplace other than what it has to cover by law and that definitely doesn't include trans specific stuff, our legislators saw to that.  Besides, the way things are going, the insurance companies may not be sure who is even covered by what where that mess is concerned. or who's paying or anything really. I'd wait and give myself time to do more research on it if I were you.

[tgchar21]

You can try looking in your state's marketplace, but remember that if your employer offers insurance you can't get subsides to help pay for it unless the employer's insurance is deemed "unaffordable" based on the percentage of your income it costs (I think it's 9.5%). Remember that although Obamacare plans aren't required to cover trans* procedures, you might still find one that does.

The deadline for enrolling in a plan for 2014 (barring special circumstances that would warrant a special enrollment period) is March 31 (it's been recently announced that there will likely be a grace period for those who started the enrollment process before 3/31) - after that you'd have to wait until later this year to enroll in a plan for 2015.

I wouldn't bother looking in the individual market - it'd be a miracle if you could find a reasonable plan that covers trans* services (and you can't get government assistance there).

[sarahbear]

I'm not planning on dropping anything anytime soon just wondering. In my case the work plan is self-funded by my employer so they fall under the aegis of a federal agency for plan requirements so even if my state were to say plans need to cover surgery it's unlikely that would effect my insurance.

It's annoying that if I were to quit and find a new job I wouldn't have any way to know whether the new employer's plan covered it either unless they were one of the major corporations that are happy to cover it.

[JennX]

No private individual plan offered by any major insurer here in the USA currently covers SRS. I went down that road about a year ago. That's just one of many things they outright exclude in individual policies. Major companies have more pull and thus can dictate the terms they want to underwrite in their policies.

[xponentialshift]

My work insurance isn't great and doesn't have an option for transgender surgery. I'm wondering if I were to decline that and buy it on my own would it be possible to transgender surgery covered? I checked out the health insurance marketplace here in my state but it's not clear whether it would be covered by even the best plans and I'm not sure exactly how to find that out. Besides that I think it would be months before I would be able to opt out of my insurance but not 100% sure how that would work either. If I try to buy without going for an individual plan (pre-packaged in the marketplace) would it be really expensive? Any advice is appreciated.

I am in basically the same situation... My insurance (through my mom) is self insured therefore federal. But I live in California and the new state mandate requires all insurance cover all trans* healthcare needs. (Federal plans exempt so I'm out of luck.)

I am thinking of looking for my own state plan for next year (for this year I can get my insurance to cover therapy and I won't see an endo as my PCP specializes in hrt)

Hopefully I get into grad school at UC Berkeley because I know their student health plan covers SRS among other things.

[asheriko35]

Hi Sara

Can you please elaborate if the insurance rejected a gender related issue (like SRS surgery) or in general rejected you for being trans?
can you mention the state and the company?
thx!

[tgchar21]

Hi Sara

Can you please elaborate if the insurance rejected a gender related issue (like SRS surgery) or in general rejected you for being trans?
can you mention the state and the company?
thx!

They can't reject you from coverage just for being trans* anymore (with the general ban on pre-existing-condition discrimination that took effect along with the other Obamacare provisions - before this year they could). Unless a state/local law dictates otherwise insurers can still refuse to cover the transition-related procedures themselves.

[tgchar21]

I am in basically the same situation... My insurance (through my mom) is self insured therefore federal. But I live in California and the new state mandate requires all insurance cover all trans* healthcare needs. (Federal plans exempt so I'm out of luck.)

Federal plans are "exempt" because the feds are not bound to recognize mandates at the state/local level. (This is the same principle as to why a state cannot tax the federal government, for example.)

[sarahbear]

Nope I wasn't rejected by the insurance company for being trans and I didn't tell them. I looked up the billing codes and asked them about that on the plan. I also dug deep into the data for the health insurance and found the exclusion there as well since the info that they passed out to all employees didn't go into that detail.

The interesting thing is that I got the billing code wrong at first and initially thought it was covered. The code I asked about was the vaginoplasty surgery for cisgender women. This makes me wonder if it could be challenged under the ACA on the basis of a procedure being covered for others but not for trans people. It seems possible but it's not an exact match on the procedures but they do have the same name and have similarities with the same goal. In addition, since I'm not in any way trans on my insurance I wish that a surgeon would be able to use the billing code that is covered but I totally understand why they wouldn't also.

BTW, self funded insurance isn't so much a federal plan as much as it is governed only on the federal level.

[Veronica M]

But I live in California and the new state mandate requires all insurance cover all trans* healthcare needs.

I also am in CA, and your post intrigues me. Being retired / Disabled I am on Medicare / Medical and also carry a very good supplemental plan. Could you please give me more information on this? Right now I am paying out of pocket for therapy which is okay, however, after looking at procedures and prices, out of pocket could be close to a 1/4 of million dollars when is all said and done if I go full boat on everything. Bottom line is I don't have that kind of money and I am concerned to say the least.

[xponentialshift]

Edit: [I'm taking out the link because I finally found the site terms and service on mobile (stickies don't stick at the top of a category in the app) and realized I shouldn't be posting a link here]

You can find info on it by googling california transgender insurance mandate...
The transgender law center has a good FAQ that I originally linked to.

Similar mandates are also in effect in Colorado Oregon and DC (CT may have passed one this year too I think)

[Veronica M]

Thank you very much for the information...