This was the message I sent my insurance company:
Can you tell me if my current plan (BlueChoice Advantage) covers female-to-male gender transition procedures? I am specifically interested in a vaginectomy, total hysterectomy, phalloplasty, scrotoplasty, urethroplasty, and placement of testicular prostheses. If these procedures are covered, can you tell me what the requirements are for demonstrating medical necessity if they are plan specific?
It took them a little over a week to get back to me with this response:
The procedures that you are inquiring on (vaginectomy, total hysterectomy, phalloplasty, scrotoplasty, urethroplasty, and placement of testicular prostheses) will fall under your Surgery benefits. There are no contract exclusions that pertain to them. Most of the services will require pre-authorization (all inpatient services require pre-authorization) and our Medical Review Nurses will review the doctor's request to determine medical necessity based on the medical information that the doctor submits.
Surgery benefits under your BlueChoice Advantage plan are as follows:
Inpatient: Considered at 100% of allowance after $1500 benefit period deductible is met. Pre-authorization required.
Outpatient: Considered at 100% of allowance after $30 copay per day per provider, once $1500 benefit period deductible is met.
Office Visit: Considered at 100% of allowance after $30 copay per day per provider, once $1500 benefit period deductible is met.
Specialist:
Inpatient: Considered at 100% of allowance after $1500 benefit period deductible is met. Pre-authorization required.
Outpatient: Considered at 100% of allowance after $30 copay per day per provider, once $1500 benefit period deductible is met.
Office Visit: Considered at 100% of allowance after $30 copay per day per provider, once $1500 benefit period deductible is met.
Facility:
Inpatient: Considered at 100% of allowance after $300 per admission copay, once $1500 benefit period deductible is met. Pre-authorization required.
Outpatient: Considered at 100% of allowance after $300 copay per day per provider, once $1500 benefit period deductible is met.
Out of Network:
Professional:
Inpatient: Considered at 70% of allowance after $3000 benefit period deductible is met. Pre-authorization required.
Outpatient: Considered at 70% of allowance after $3000 benefit period deductible is met.
Office Visit: Considered at 70% of allowance after $3000 benefit period deductible is met.
Facility:
Inpatient: Considered at 70% of allowance after $3000 benefit period deductible is met. Pre-authorization required.
Outpatient: Considered at 70% of allowance after $3000 benefit period deductible is met.
Please be mindful that out of network providers can balance bill up to the charged amount.
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So essentially, with an in-network provider at an in-network facility, I can expect to pay $1500 towards my annual deductible, plus a $30 copay per day per provider, and a $300 copay to be admitted to the hospital for the procedure. Insurance will cover all other expenditures that are deemed medically necessary at that point.
Another point to know - My annual out of pocket maximum for in-network providers is $4000. The value of my deductible and all of those copays factors into the out of pocket maximum. So, if something were to go wrong and I needed to be re-admitted to the hospital, I'd pay another $300 admission copay and $30 copays to any doctors I see - and that all goes towards my out of pocket maximum. When I get to $4000, I have met my financial obligation as a patient for the benefit period. I am not expected to pay anything else towards my in-network care for the remainder of the benefit period.
So best practice = schedule your initial stage right around the beginning of your benefit period to maximize your benefits and lower your expected costs. If you can get multiple stages done in a calendar year (which many surgeons will do), that's just admission copays and doctor copays until you hit the maximum and then you're done with bills until your policy renews the following year.
Now - out of network. My out of network out of pocket maximum is $6000, and my deductible is $3000. So I'd have to pay $3000 just to get the ball rolling. Then - as long as everything has been approved in advance - insurance will pay 70% of those approved expenses. The surgeon and hospital can each then bill you for any outstanding charges. If you're going to an out of network provider, you should make every attempt to get a single case agreement first. This says exactly what your insurance is willing to pay for each part of the procedure. Then, you should try your darndest to get a gap exception, which would have your insurance company consider your surgeon as an in-network provider just for your surgery. This is easy to do if there are significant differences in technique between the surgeon you want to go to and the surgeon(s) you have access to in-network.
Hope this helps! Happy to go into more depth if needed.
