How can I get my employer's health plan to cover my transition?

[ShadowCharms]

I have health insurance through my job, which both employer and I pay for each month. Unfortunately, I found out after I started transitioning that my health plan has an exclusion for any health treatments related to gender identity. This is what my coverage documents say specifically: (in the list of exclusions) "Charges for or related to sex change surgery or to any treatment of gender identity disorders."

Right now, I have to pay full price out of pocket to see my doctor at the women's health center; because she includes a code for transgender care when submitting to my insurance, they outright refuse to cover my visits with her (they don't even leave any comments when refusing her payment requests). This happens despite the fact that visits with both regular doctors and specialists are covered with a copay under my insurance. My hormones and blood tests somehow get paid for. I'm guessing that those are just not being reported as being related to gender identity by the people submitting them to insurance.

Last year I emailed the person in charge of health benefits for my employer to ask her why gender identity was in the list of exclusions, and if that might be lifted in 2015. Her response was to completely ignore my question about why they weren't covering transgender health issues, and to tell me that it wouldn't be changing in 2015 unless mandated by law. She did specify that she was "sorry that I didn't get the answer I wanted".

I contacted Lambda Legal to find out if there was a way to make my employer remove their exclusion. They told me that since my employer has a private insurance policy, they can exclude transgender health coverage if they want.

I checked my coverage documents for 2015, and the exclusion is still in there. I'm thinking of emailing our benefits department again this year to ask if the exclusion might be lifted in 2016. This time around, I would like to challenge them on it if they say no. Has anyone managed to get their employer to lift their exclusions for transgender health care? Does anyone have suggestions about what I might do to convince my employers that they are denying me medically necessary health care under the coverage I pay for?

[jeni]

I have not, but I think mine has a similarly worded exclusion and they seem to be covering hormones and even the endo office visit so far. At the moment I'm not asking questions and we'll see what happens. My employer is a state university and have a non-discrimination policy that expressly protects gender identity, so if I do run into trouble I think they might have a hard time justifying insurance coverage that grossly violates their own non-discrimination policy.

On the other hand, it's a big institution and I'm not anticipating major health care costs soon, so I'm not sure how much effort I'd put into fighting the good fight if it came to that.

[Mariah]

A couple of things to remember often their are workarounds as far the coding to get insurance to cover things. Secondly, in some states they have made ruling that require insurance carriers to cover something for us that they are covering for others for other reasons.
Mariah

I have health insurance through my job, which both employer and I pay for each month. Unfortunately, I found out after I started transitioning that my health plan has an exclusion for any health treatments related to gender identity. This is what my coverage documents say specifically: (in the list of exclusions) "Charges for or related to sex change surgery or to any treatment of gender identity disorders."

Right now, I have to pay full price out of pocket to see my doctor at the women's health center; because she includes a code for transgender care when submitting to my insurance, they outright refuse to cover my visits with her (they don't even leave any comments when refusing her payment requests). This happens despite the fact that visits with both regular doctors and specialists are covered with a copay under my insurance. My hormones and blood tests somehow get paid for. I'm guessing that those are just not being reported as being related to gender identity by the people submitting them to insurance.

Last year I emailed the person in charge of health benefits for my employer to ask her why gender identity was in the list of exclusions, and if that might be lifted in 2015. Her response was to completely ignore my question about why they weren't covering transgender health issues, and to tell me that it wouldn't be changing in 2015 unless mandated by law. She did specify that she was "sorry that I didn't get the answer I wanted".

I contacted Lambda Legal to find out if there was a way to make my employer remove their exclusion. They told me that since my employer has a private insurance policy, they can exclude transgender health coverage if they want.

I checked my coverage documents for 2015, and the exclusion is still in there. I'm thinking of emailing our benefits department again this year to ask if the exclusion might be lifted in 2016. This time around, I would like to challenge them on it if they say no. Has anyone managed to get their employer to lift their exclusions for transgender health care? Does anyone have suggestions about what I might do to convince my employers that they are denying me medically necessary health care under the coverage I pay for?

[JustASeq]

I have health insurance through my job, which both employer and I pay for each month. Unfortunately, I found out after I started transitioning that my health plan has an exclusion for any health treatments related to gender identity. This is what my coverage documents say specifically: (in the list of exclusions) "Charges for or related to sex change surgery or to any treatment of gender identity disorders."

Right now, I have to pay full price out of pocket to see my doctor at the women's health center; because she includes a code for transgender care when submitting to my insurance, they outright refuse to cover my visits with her (they don't even leave any comments when refusing her payment requests). This happens despite the fact that visits with both regular doctors and specialists are covered with a copay under my insurance. My hormones and blood tests somehow get paid for. I'm guessing that those are just not being reported as being related to gender identity by the people submitting them to insurance.

Last year I emailed the person in charge of health benefits for my employer to ask her why gender identity was in the list of exclusions, and if that might be lifted in 2015. Her response was to completely ignore my question about why they weren't covering transgender health issues, and to tell me that it wouldn't be changing in 2015 unless mandated by law. She did specify that she was "sorry that I didn't get the answer I wanted".

I contacted Lambda Legal to find out if there was a way to make my employer remove their exclusion. They told me that since my employer has a private insurance policy, they can exclude transgender health coverage if they want.

I checked my coverage documents for 2015, and the exclusion is still in there. I'm thinking of emailing our benefits department again this year to ask if the exclusion might be lifted in 2016. This time around, I would like to challenge them on it if they say no. Has anyone managed to get their employer to lift their exclusions for transgender health care? Does anyone have suggestions about what I might do to convince my employers that they are denying me medically necessary health care under the coverage I pay for?

I got my employer to adopt trans-inclusive benefits this year. They will be effective in March of this year. I work for a large international non-profit and basically would not drop it and moved to the highest people possible. I said that there were plenty of campaigning groups that would love the media publicity of campaigning against them. I also, before doing this, had figured that on unemployment I would make just enough to pay rent, utilities and medical insurance/medical costs for at least some amount of time. I started the conversation close to a year ago, and it was really frustrating and seemed to move super slow.

I would assume your doctor does what mine does and codes your treatment as something else that is covered. My doctor is currently doing the same thing. It will change once I go back in 2 months, I talked with my doctor about this a few days ago. Another change because of all of this is that my insurance provider will provide a case manager to help me with my medical transition. I just hope not too much changes, I have been happy with things so far and would hate for them to limit my current dosages or for something weird like "it wasn't transitioning HRT since it wasn't diagnosed that way" or something along those lines when going through the process of setting up my SRS.

This being said, definitely not the case for everyone. I hope you get this worked out and encourage you to not just give up. Depending on the size of your employer, they may be willing to pay a portion of a different private insurance plan of your choice. I have friend who was able to do this through her work., but she works for a very small company. Just try and find out what your options and alternatives are, no matter how unconventional in comparison to just having the coverage that trans people need.

[ImagineKate]

What state?

NY now requires insurers in NY state to cover trans care. Other states may be similar.

However, my visits are integrated with my primary care and billed as such. It helps that I use spiro to treat high blood pressure. Therapy is even partially covered. So all I pay for my dr visits are a $15 copay. For my medicines the copay is anywhere from $0 to $5. $5 copays are reduced to $4 by walmart. Estradiol pills get bounced back from the prescription plan for some reason and I haven't bothered to fight it (they're supposed to cover it) so I just get it filled at walmart for $10/90 pills.

Anyway what I'd suggest is to get a doctor who will do your HRT and integrate it with your primary. You don't really need an endo. Prescribing HRT and running tests is not that complicated, at least not for any licensed physician.

[ShadowCharms]

It's hard for me to tell exactly which state laws apply for my employer. My department is in Colorado, but the company is international. My employer's main office is in New York, but our health benefits are actually handled by our parent company, which is has a local branch in New York, and their main office in London. Technically, our benefits office is in New York, so I don't know if that would help my case.

[KarynMcD]

But what office do you work out of.

[jessical]

If you are part of the Colorado office, then they must follow Colorado law.  I don't know if transgender care is required in Colorado, but if not I think you have a good argument to make with the Benefits people in NY, that you should be treated the same as NY employees.

[ShadowCharms]

I work in Colorado.