How much to share with the insurance paper pushers

[debbiej]

My therapist suggested that I start investigating what the insurance company needs to know to authorize HRT. I hesitate to call an insurance company paper pusher and announce that I am transgender and ask what they will cover. Do I need to tell them anything? Or can I just start seeing an endo and turn in a prescription? My insurance is HighMark Bluecross Blueshield. Does anyone have experience with HRT coverage and this company?

Thanks

Debbie

[Sarah Louise]

Usually your insurance provider will give you a book that shows what is covered and what is not.

I have BlueCross through my wife's work and it "specifically excludes" anything to do with TS.

Sometimes your doctor can send it in as hormonal problems and not explain too much.


Sarah L.

[Steph]

Generally speaking insurance companies don't ask what the prescription is for, they just need an official prescription submitted with the claim in order for them to reimburse any costs.  As mentioned above your insurance provider should be able to provide a list of services covered and what if any medications are covered.

My own insurance company reimburses me for all my scripts including HRT, and Electro.  I just include the original prescription with the claim form.

Steph

[debbiej]

Usually your insurance provider will give you a book that shows what is covered and what is not.

I have BlueCross through my wife's work and it "specifically excludes" anything to do with TS.

Sometimes your doctor can send it in as hormonal problems and not explain too much.

Thank you so much. I'm so glad I asked. I don't like to be deceitful but I don't see a need to share my specific need for hormones if doing so causes an unjust decision about my medical care.

Debbie 

[SusanK]

Thank you so much. I'm so glad I asked. I don't like to be deceitful but I don't see a need to share my specific need for hormones if doing so causes an unjust decision about my medical care.

You shouldn't have to say anything, let the physician file the forms for the visits and you fill the prescriptions. Even the pharmacist(s) shouldn't ask or say anything except the usual warnings about drugs. You'll be surprised that hrt isn't sex/gender specific anymore and covered. There are so many flavors of Blue Cross/Blue Shied it's hard to know but the umbrella insurer should send you a booklet with the full details, and it likely excludes any coverage by name, but that's for ffs, srs, etc., not routine stuff of life. They should have an on-line version if they didn't send you one.

Personally I would recommend you never mention it to anyone with your insurer, and your therapist shouldn't either if/when they submit bills for coverage. Most have a proportion payment for general therapy, meaning no specific diagnosis or treatment plan. Most have a certain number of visits per year covered about 40-60% of the fee. It should be described in the booklet with a list of approved therapists.

Good luck.

[Sheila]

When I first started on hormones, I had bluecross blueshield. I just handed the pharmacy my presciption and they billed insurance company. I got my hormones and I didn't say a word. To this day no one has asked me and I have been through 3or 4 insurance companies. I have gone to the same pharmacist for the last 25 years and they know about me, but they never asked me for insurance reasons.
Sheila

[debbiej]

Thank you thank you thank you thank you!!!!!

My wife found the book for me and there is no mention of TS or TG in the "What the Plan Does Not Cover" section. So I will let sleeping dogs lie and and have the doctor/pharmacist turn in my paperwork when the time comes.

I'm excited and just a little nervous about taking this next step. Thanks again for your assurances and advice.

Debbie

[tinkerbell]

Hmmmm...tricky issue Debbie.  First, I would investigate what your insurace company policy is regarding treatment for TS people.  Some insurance plans will cover HRT and therapy if your doctor(s) can convice them to do that.  Others will not cover a thing regardless of what the physician tells them. 

If you are still listed as M on their records, you may encounter problems in regards to estrogen therapy.  Getting a hard copy of your insurance plan and talking to a friendly representative might be the right approach.  I work in health care, and I know many TS people who receive hormones and therapy free of charge despite the fact that they are still listed as their birth sex on insurance plans, so there is hope. 

tink

[SusanK]

My wife found the book for me and there is no mention of TS or TG in the "What the Plan Does Not Cover" section. So I will let sleeping dogs lie and and have the doctor/pharmacist turn in my paperwork when the time comes.

Did you read it thoroughly? Not to say you didn't but they may not use those words, and use terms such as sex transformation, sex transistion, etc. Look under all things about "sex". But this type of terminology opens the door to interpretation on both sides.

The irony is that the exclusions make exceptions for "medically necessary to prevent, diagnose, or treat your illness, disease, injury or condition", and technically the DSM-IVR does list GID as mental health condition. I wonder when all is said and done after getting a change of gender notification from a insured they weigh the costs provided versus the costs to get and fight for a reimbursement, and decide to let things go.

--Susan--

[Jordan]

Acually most insurance companies list it as a Pre Existing medical condition...

They will cover it but not for X period of time, but dont tell them, oh no If they find out they will likely cut it...

Its all in the Doctors coding he uses when he bills your HMO, The way HRT gets past insurance companies is coding it as a Hormonal Imblance, not HRT...

Ask your docotr to do you a favor and code it so it will get paid for... you know, they really are on your side to some degree.

[debbiej]

Did you read it thoroughly? Not to say you didn't but they may not use those words, and use terms such as sex transformation, sex transistion, etc. Look under all things about "sex". But this type of terminology opens the door to interpretation on both sides.

I think I read it pretty thoroughly. And you make a very good point concerning opening the door for "interpretation". I have a good friend, Mike, that used to work for an insurance company as one of those persons that reviewed health insurance claims (I callously called those people Paper Pushers in my original question - Sorry Mike). He was told to refuse claims as a matter of course. Of course he didn't refuse all claims and erred on the side of accepting legitimate claims. That's why he used to work for them and now has a job that better fits his moral compass. I've also had to deal with a major property claim and spent hours and hours agonizing and arguing with adjusters until they finally (from my point of view) did the right thing and honored a claim. It was all about trying to get them to honor my "interpretation" of the policy. Quite honestly it could have gone either way. I understood their interpretation but my trump card was that I was not arguing for my own gain, I was arguing for the not-for-profit organization where I worked. And in the end we didn't get everything I felt we deserved but enough to keep us from laying off a staff member and doing less ministry because of what the insurance company refused to pay out. 

Its interesting that the first adjuster I talked to - the one that visited the site - At first he told me they probably would NOT cover the loss - but after spending an hour or two with him and explaining my views he left me with some real hope that there would be a settlement. As soon as he turned in his report they (the insurance company) turned the claim over to another adjuster that stonewalled me.

Insurance companies are NOT in the business of helping their customers. They are in the business of making money. They make money by collecting premiums and NOT paying out claims so you may have to manipulate the system to get what you feel you are due.

I know all this sounds cynical and I try not to be that way - I try to do things as honestly as I can but my life experience with the Insurance industry has not been good. The thing is, most of the individuals I've dealt with in the insurance industry have been good people. Its the industry that gives me fits.

Anyway thank you for all your views on this matter and letting me vent my frustrations in this particular post.

Debbie

I just saw your post Mara. Just last night I found a group in my area that has a web directory of trans friendly professionals. I bet I can find a doctor on that list that will code my bill in a helpful way. While I am new to my new job I am working for the same denomination and my insurance carries over from my previous position.

Debbie

[joannatsf]

Usually your insurance provider will give you a book that shows what is covered and what is not.

I have BlueCross through my wife's work and it "specifically excludes" anything to do with TS.

Sometimes your doctor can send it in as hormonal problems and not explain too much.

Thank you so much. I'm so glad I asked. I don't like to be deceitful but I don't see a need to share my specific need for hormones if doing so causes an unjust decision about my medical care.

Debbie 

Hi Debbie,  A rule that I use in all areas of dealing with officialdom is; Never volunteer information.  If you're getting generic estrogen and spironolactone the cost is ust a few dollars to them.  It should sail right through!

[NicholeW.]

Never volunteer info about yourself is absolutely right.

The endo, I presume that is where you'll be getting scripts should probably submit a diagnosis of something like 'hypo-gonadism' which seems rather usual in such cases. Otherwise to pay for scripts all the company needs to know is that you are paying for them through insurance.

Not something you actually need to check on. If you do it'll send out a red-flag. If they refuse payment THEN you start digging with the help of the endo's office staff. They have navigated this path before in all likelihood and should know their way around. I cannot imagine that you'll ever hear about it again though.

N~

[Christine Eryn]

The last time I saw my doctor, she inquired if anyone at the pharmacy asked me why was I taking female hormones. I said nope. It's because pharmacists have called her up and basically said "are you sure this perscription is for him?" She said "yep" and that was the end of it.

So when I looked on the paper of the explaination packaged with the Estradiol I'm taking it says:
to treat certain symptoms of menopause or to prevent osterporosis; it is also used to treat breast cancer and prostate cancer
I guess I would use the "brittle bones" idea if questioned too much. Other than that I would tell whoever, like the insurance companies, hey it's what my doctor perscribed, you gonna argue that?

[debbiej]

Thanks for sharing your experience Christine!!

I'm going to plow ahead and share my experiences with you all. I see my therapist again on Tuesday and see how soon she'll feel comfortable giving me a letter. Jumping through hoops and trying to circumvent them when needed. I AM committed to doing this with as much professional help as I can get to stay safe.

Debbie

[NicholeW.]

Thanks for sharing your experience Christine!!

I'm going to plow ahead and share my experiences with you all. I see my therapist again on Tuesday and see how soon she'll feel comfortable giving me a letter. Jumping through hoops and trying to circumvent them when needed. I AM committed to doing this with as much professional help as I can get to stay safe.

Debbie

DO NOT talk to the insurance company. If they call you refer them to your endo who will be able to explain. You need not, and if you're smart, will not, tell your insurance anything unless you have read you group policy and find that HRT for the purposes of a 'sex change' is an allowable set of procedures (in some states it is and on some company policies it is.)

You turn in the script, pharmacy will call the doc, as in Christine's case, if any call is made,; you get the filled script. Simple. Do not call anyone other than your endo. In this case you therapist is absolutely wrong. Betcha her/his insurance doesn't require her/him to call and check with them if any particular script is covered. She/He fills them and pays the co-pay. Period.

So will you. Any pre-approval required will be handled by the doctor's office: they know what they are doing.

All the therapist will do is provide a referral to the endo.



N~

[tekla]

HIPPA does not prevent insurance companies from sharing information with other insurance companies.  Guess who wrote that law.

[NicholeW.]

HIPPA does not prevent insurance companies from sharing information with other insurance companies.  Guess who wrote that law.

A lawyer, of course. Probably a group of them, many of whom were being lobbied by insurance companies.

N~

[debbiej]

A lawyer, of course. Probably a group of them, many of whom were being lobbied by insurance companies.

N~

UUUUUURRRRRGGGGHHHHHH!!!!!!!!!!!!!!

How incredibly frustrating that our world has been taken over by greedy corporations. How did we let this happen?

That said, I'll reiterate an earlier comment with some other words. Its not the people who are the problem, its the system. I know several good people that work in the insurance industry and I just had lunch with an incredibly wonderful woman who is a lawyer. Wonderful people with good hearts but the system that they work in has become evil. Its called institutional evil. Its insidious.

Debbie

[NicholeW.]

A lawyer, of course. Probably a group of them, many of whom were being lobbied by insurance companies.

N~

UUUUUURRRRRGGGGHHHHHH!!!!!!!!!!!!!!

How incredibly frustrating that our world has been taken over by greedy corporations. How did we let this happen?

That said, I'll reiterate an earlier comment with some other words. Its not the people who are the problem, its the system. I know several good people that work in the insurance industry and I just had lunch with an incredibly wonderful woman who is a lawyer. Wonderful people with good hearts but the system that they work in has become evil. Its called institutional evil. Its insidious.

Debbie

I cannot disagree with that at all. I have a very dear friend who is also a very excellent attorney. She is TS/IS, works cases among other things in establishing 'rights' for TS and working toward a country that is at least less discriminatory than the one we currently live in.

I have made acquaintances with all sorts of 'administrators' and others who are very dear people who happen to work at places like Aetna and a couple of BC/BS insurance groups. In damning attorneys I always 'dis-include' my friend, my former bankruptcy attorney, a woman in my graduate program, another friend who worked for years as an attorney who now is a therapist, etc, etc.

They are all, in my estimation, 'good people' who are in a line of work that I normally associate with conniving and disingenuity. Yet, I also realize that in the system we have in place that change comes at a snail's pace and that those friends and acquaintances are working within that nasty system to make 'change.'

I despair a lot about their ever being able to make those changes from within, so much of their well-being and lives are tied to the system that I imagine how difficult it must be to try to effect change.

But, I am happy to know they are there. That at least leaves the possibility that positive (in my eyes) changes will be made.

Nichole