Will insurance ever pay?

[Amy1988]

I'm confused about the Afordable Care Act.  The recent proposed changes preventing discrimination against transgender people but stops short of SRS and I'm guessing orchiectomy too.  So should I just go ahead and dig into my own pocket and pay for an orchiectomy and eventually SRS or hold out to see if insurance will be required to pay for these procedures? I don't know how to proceed and holding up progress. 

[Maybebaby56]

Hi Amy,

My insurance (Aetna HMO) states that it covers SRS and orchiectomies, if prior approval is obtained before the procedure. I will admit, I have not yet contacted them to find out what is involved in the approval process, as that is pretty far down the road for me.

Since Federal law now prohibits discrimination against Transgender health care for Federal employees, more insurance companies now cover this in their policies.  I would shop around.

Terri

[Tessa James]

Amy I wish their was greater uniformity after the ACA but a lot still depends on your specific insurance plan and even what state or city you live in.  Several states and the District of Columbia including California, Colorado, and Washington basically now mandate equity in coverage and have mostly eliminated the "exclusionary riders" that discriminate against us as a class of people.  I live in Oregon where the Oregon Health Plan and several private plans provide coverage but just finding a surgical clinic that takes that insurance is daunting.

Part of our struggle has to do with the WPATH definitions of what is medical necessity.  My insurance company insists that what i want (orchiectomy) is cosmetic and they clearly use different guidelines in an attempt to legitimize what i believe is prejudicial and discriminatory.  If you are refused or denied care please consider filing an appeal.  We can and will prevail but it takes people standing up and challenging the inequitable status quo.

[Venus]

This might be helpful, but it mostly involves moving...

I did find this page which mentions a few ways you can get insurance to cover your stuff. There's at least a way to start off with insurance coverage:

There are ways to get around insurance exclusions. Sometimes hormones can be covered if your doctor uses hormone imbalance, or some other non-gender identity related, diagnosis. Gender identity counseling can be often covered if your therapist uses an anxiety or adjustment disorder diagnosis code.

This is from Blue Cross/Blue Shield: Our Medical Affairs Department indicated that it is generally accepted among professionals that an adult with gender identity disorder who experiences anxiety and stress as a result of the disorder should be treated. Mental health services billed with an anxiety or adjustment disorder diagnosis code would be covered under the mental health benefits available on the plan.

Of particular note however:

• Minnesota's public assistance covers SRS. If you can work, Medica insurance in Minnesota covers SRS, as well as gender therapy and hormones.
  
• Another option is moving to California. As far as I know, their public health insurance (Medi-Cal) will cover SRS. Also, anyone who is an employee of any campus of the University of California will be covered.
  
• Also, Medicaid is increasingly covering SRS
  
• Some provinces in Canada (I believe Alberta does) pay for SRS

Minnesota's public assistance covers SRS.

If you're referring to Medical Assistance, no, it doesn't cover SRS. It does cover other transition related health care, but the legislature passed a law in 2005 which specifically forbids MA to cover SRS.

We're working to change that, but at the moment, that's the status quo.

Of course definitely check for certain if those areas cover what you're wanting if you do ever intend to move for the purposes of having SRS covered. At this point it doesn't look like moving somewhere for a few years for transition costs to be covered is a horrible idea when compared to having to fund them directly, but that's definitely not an option for most I'd imagine.

[lisarenee]

Some insurers already cover it on certain group plans. I'm pretty sure mine does, but if I go through insurance I would still have to cover my deductible and coinsurance, plus deal with a nearly year and a half waiting list, and limited options for surgeon.