Getting Top Surgery Covered by Insurance?

[Contravene]

I'm looking for some advice from anyone who's successfully had insurance cover all or part of the cost of their top surgery. Any experiences would be appreciated.

I'll be a year on T in February and I'm ready to make the next step in my transition, it's also good timing for it in my personal life, but I can't afford to just pay out of pocket for top surgery and I have no idea where to start with even trying to get it covered by insurance.

Right now I have a PA Medicaid plan with United Healthcare. My current plan doesn't cover any form of gender reassignment surgery (I called to make sure and to try to get more information but as soon as I mentioned gender reassignment surgery the guy I was talking to became a total ass).

I have heard of medicaid plans with different insurance companies that will cover top surgery but I'm not sure how to find which ones they are or where to go from there. I have a few companies in mind as well as a few surgeons I'd like to get consults with sometime in 2017 but for some reason I'm so dumb when it comes to this, it's almost like I need a guide on what to do.

[FTMax]

Visit out2enroll.org. They can help you find a plan that works for you. It's free.

[Farm Boy]

My therapist was under the impression that due to HHS Section 1557, enacted earlier this year, I'd be able to get my top surgery covered.  This law makes it illegal for insurance companies that receive federal funding (most insurance) to have blanket transgender exclusions.  You can read more about it here: https://transgenderlawcenter.org/archives/12908 That's actually what got me to finally schedule my surgery.  My plan did have an exclusion for any trans services, and when I called my insurance before they said it'd be no problem come January.  Well, my plan policy has renewed, and it still has an exclusion.  I'll have to call them again.  Might be something to look into?

[patrick1967]

I'm waiting to see what my new plan says. From my understanding if a ins company takes ANY federal payments, medicare, marketplace etc, they cannot put out a blanket exclusion, but i am not a lawyer. I have the info somewhere about who to contact with complaints, I'll have to dig it up. I'd love to have someone experienced in the law weigh in with some links for where to get assistance

The link to the text of the section:
https://www.hhs.gov/civil-rights/for-individuals/section-1557

[CursedFireDean]

As everyone said, companies with federal funding cannot have blanket exclusions. This starts January 1, but specifically it starts the first plan period AFTER January 1. My plan doesn't renew until July 1 for example so I have to deal with the exclusion until July 1. (Which is stupid imo that they can discriminate against me for longer, but whatever I can't do anything and I can't afford my deductible until the plan renews anyways)

Specifically, they cannot discriminate because of sex. July 18, 2016 they ruled that "sex" includes gender identity and that companies had until January 1, 2017 to comply. "The first day of the first plan period beginning after January 1." For the marketplace plans, that should be January 1, but different policies have different dates. I don't know about Medicaid.

They clarify that they are not requiring plans to include services, they decide whether it's discrimination based on if the treatment would be covered for other diagnoses. For example my plan covers testosterone for men with low T, boys with delayed puberty, and women with inoperable breast cancer. Therefore when my plan renews, NOT covering it for trans people specifically because of the trans diagnosis would be discrimination and illegal. If however they decided to quit covering testosterone for ANYONE, they could still deny a trans person because in that case it isn't discriminating against trans people.

To read more about what they say regarding gender identity, search "ACA section 1557 final ruling". I would add a link but I'm on mobile and it's very difficult.

But again, I also am not a lawyer and you should consult someone qualified to give legal advice.

[patrick1967]

I posted a link earlier for the text of the new guidelines. For reference this is the portion that concerns trans care. As Dean said I am also not an attorney, but the language is pretty clear.


§ 92.206
Equal program access on the basis of sex.

A covered entity shall provide individuals equal access to its health programs or activities without discrimination on the basis of sex; and a covered entity shall treat individuals consistent with their gender identity, except that a covered entity may not deny or limit health services that are ordinarily or exclusively available to individuals of one sex, to a transgender individual based on the fact that the individual's sex assigned at birth, gender identity, or gender otherwise recorded is different from the one to which such health services are ordinarily or exclusively available.

§ 92.207
Nondiscrimination in health-related insurance and other health-related coverage.

(a) General. A covered entity shall not, in providing or administering health-related insurance or other health-related coverage, discriminate on the basis of race, color, national origin, sex, age, or disability.

(b) Discriminatory actions prohibited. A covered entity shall not, in providing or administering health-related insurance or other health-related coverage:

(3) Deny or limit coverage, deny or limit coverage of a claim, or impose additional cost sharing or other imitations or restrictions on coverage, for any health services that are ordinarily or exclusively available to individuals of one sex, to a transgender individual based on the fact that an individual's sex assigned at birth, gender identity, or gender otherwise recorded is different from the one to which such health services are ordinarily or exclusively available;

(4) Have or implement a categorical coverage exclusion or limitation for all health services related to gender transition; or

(5) Otherwise deny or limit coverage, deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions on coverage, for specific health services related to gender transition if such denial, limitation, or restriction results in discrimination against a transgender individual.

(c) The enumeration of specific forms of discrimination in paragraph (b) does not limit the general applicability of the prohibition in paragraph (a) of this section.

(d) Nothing in this section is intended to determine, or restrict a covered entity from determining, whether a particular health service is medically necessary or otherwise meets applicable coverage requirements in any individual case.

Info on filing complaints can be found at https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html

[FTMax]

As I understand it, the new law doesn't necessarily apply to employer provided benefits. So if your plan is through your employer or parent/spouse's employer, you may still have to deal with exclusions.

But if it is a marketplace plan or Medicare/Medicaid, they have to cover for you what they would cover for a cisgender person. Like Dean noted, if they cover TRT for cisgender males with low testosterone, they then must cover HRT for you as a person with a diagnosis of gender dysphoria. If they would cover a bilateral mastectomy for a cisgender female with breast cancer, they must cover a bilateral mastectomy for you as a person with a diagnosis of gender dysphoria. The new law essentially just takes gender requirements out of the picture and goes solely on the basis of medical necessity.

But that doesn't necessarily mean you will be in for an easy time. I have inclusive coverage as mandated by the state I am insured in. Coverage for my hysterectomy was initially denied because I am listed as male on my insurance. Men do not have uteruses (uteri?). My doctor appealed on my behalf and argued that coverage should be granted due to my being a transgender man, and my plan covering hysterectomies for cisgender women. She also threatened to involve the Office of the Healthcare Ombudsman if they would not cover me. It took the threat of legal action to get them to pay up, in a state where they are required and have been required for over 3 years to provide equal coverage to trans patients. So just because the law is on your side does not mean you will not have to endure some headaches.

[patrick1967]

Headaches are part and parcel of our lives. It may mean some fights, but damned if I am going to stop working towards it. And from what I was told by a friend who is an attorney is that employer health plans, if they are administered or offered through an insurance company that gets federal payments and not fully self administered and paid, are covered under the new rules. We'll see once  January 1st hits

[Farm Boy]

I called my insurance company back, and the guy wasn't terribly helpful.  He said my plan had updated Jan. 1st, and 'your plan didn't cover it last year, so it won't cover it this year.'  He also said he didn't know what the ACA was, and was not at all interested in Section 1557.  "No, that information will not be helpful."  If I can't talk to my insurance company about this, who am I supposed to talk to?  I will call again when I'm feeling slightly less frustrated.  Sounds like I'll end up just appealing and then filing a complaint against them afterwards.  Anybody else?

[patrick1967]

Currently there is an injunction issued out of Texas that has the whole "gender" issue on hold with the ACA, so as of now it does not have to be covered. Either download or request a copy of your complete benefit book and see what the legal language says

[Contravene]

I appreciate all the info. I was told that my new plan (it just renewed actually) should cover anywhere from 50% to 75% of any sort of gender reassignment surgery including too surgery. I was thinking of going to Kathy Rumer in Philly since it's not too far for me and I like the D.I. results I've seen from her. The last I heard she's just waiting to be approved to accept Medicare and Medicaid. I'm going to give her a call to be put on a waiting list for when she is approved then see where to go from there.