Insurance coverage

[ZeldaHeart]

Hi everyone.  As you know, SRS is super expensive, so it would be super helpful if your insurance covered it, right?  After reading something on a blog about someone's insurance covering her SRS, I looked up my insurance and found out that they MIGHT cover it.

Read below.

Note: Most Aetna plans exclude coverage of sex change surgery (gender reassignment surgery, transgender surgery) or any treatment of gender identity disorders.  Please check benefit plan descriptions.

Aetna considers sex reassignment surgery medically necessary when all of the following criteria are met:

    Member is at least 18 years old; and

    Member has met criteria for the diagnosis of "true" transsexualism, including:
        A sense of estrangement from one's own body, so that any evidence of one's own biological sex is regarded as repugnant; and
        A stable transsexual orientation evidenced by a desire to be rid of one's genitals and to live in society as a member of the other sex for at least 2 years, that is, not limited to periods of stress; and
        Absence of physical inter-sex of genetic abnormality; and
        Does not gain sexual arousal from cross-dressing; and
        Life-long sense of belonging to the opposite sex and of having been born into the wrong sex, often since childhood; and
        Not due to another biological, chromosomal or associated psychiatric disorder, such as schizophrenia; and

        Wishes to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and

    Member has completed a recognized program of transgender identity treatment as evidenced by all of the following:
        A qualified mental health professional* who has been acquainted with the member for at least 18 months recommends sex reassignment surgery documented in the form of a written comprehensive evaluation; and
        For genital surgical sex reassignment, a second concurring recommendation by another qualified mental health professional * must be documented in the form of a written expert opinion**; and
        For genital surgical sex reassignment, member has undergone a urological examination for the purpose of identifying and perhaps treating abnormalities of the genitourinary tract, since genital surgical sex reassignment includes the invasion of, and the alteraton of, the genitourinary tract (urological examination is not required for persons not undergoing genital reassignment); and
        Member has demonstrated an understanding of the proposed male-to-female or female-to-male sex reassignment surgery with its attendant costs, required lengths of hospitalization, likely complications, and post surgical rehabilitation requirements of the planned surgery; and
        Psychotherapy is not an absolute requirement for surgery unless the mental health professional's initial assessment leads to a recommendation for psychotherapy that specifies the goals of treatment, estimates its frequency and duration throughout the real life experience (usually a minimum of 3 months); and
        The member has successfully lived and worked within the desired gender role full-time for at least 12 months (so-called real-life experience), without periods of returning to the original gender; and

        Unless medically contraindicated, member has received at least 12 months of continuous hormonal sex reassignment therapy recommended by a mental health professional and carried out by an endocrinologist (which can be simultaneous with the real-life experience).

* At least one of the two clinical behavioral scientists making the favorable recommendation for surgical (genital) sex reassignment must possess a doctoral degree (e.g., Ph.D., Ed.D., D.Sc., D.S.W., Psy.D., or M.D.). Note: Evaluation of candidacy for sex reassignment surgery by a mental health professional is covered under the member's medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional's services are covered under the member's behavioral health benefit. Please check benefit plan descriptions.

** Either two separate letters or one letter with two signatures is acceptable.

Medically necessary core surgical procedures for female to male persons include: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty and placement of testicular prostheses, and erectile prostheses.

Medically necessary core surgical procedures for male to female persons include: penectomy, orchidectomy, vaginoplasty, clitoroplasty, and labiaplasty.

Note: Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction thyroid chondroplasty, hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which have been used in feminization, are considered cosmetic. Similarly, chin implants, nose implants, and lip reduction, which have been used to assist masculinization, are considered cosmetic.

Note on gender specific services for transgender persons:

Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy. Examples include:

    Breast cancer screening may be medically necessary for female to male transgender persons who have not undergone a mastectomy;
    Prostate cancer screening may be medically necessary for male to female transgender individuals who have retained their prostate.

Does the note at the beginning mean that even if all of that stuff is met, my insurance still might not cover it?  Also, was/is your SRS going to be covered by your insurance?  What's your experience with this?

[LordKAT]

Transitioning is specifically not covered under my insurance. they are covering HRT thankfully.

[Michelle.]

Note: Most Aetna plans exclude coverage of sex change surgery (gender reassignment surgery, transgender surgery) or any treatment of gender identity disorders.  Please check benefit plan descriptions.

Aetna considers sex reassignment surgery medically necessary when all of the following criteria are met:


I translate this as the following.

If, if, your contracted plan covers trans related care. We will cover it, provided you meet this long list of requirements.

[Cen]

It sounds like most of their plans exclude GRS, while some allow it.

[Caith]

CIGNA is a major supporter of transgender medical needs, including surgery.  While my employer's health insurance charter explicitly excludes transgender therapy, medications, and surgical procedures, CIGNA is their claims administrator and has not denied any of my therapy, psychiatry, or monthly hormone claims.

[regan]

Insurers are willing to cover literally anything, provided the right premiums are paid by your employer (or yourself).  I would check with HR, and you'd have to ask them specifically to see if your plan covers SRS.  If its not covered, ask why or ask what it would take to get it covered.  The additional premium might not be that substantial (I have no idea) and it would certainly improve your employers GLBT-friendly image.

If nothing else, there is precedent for you to deduct the cost of the surgery, etc on your taxes.

[Caith]

If nothing else, there is precedent for you to deduct the cost of the surgery, etc on your taxes.

I will certainly be claiming the $2500 expense of my orchiectomy (and travel and lodging expenses, if possible) as an uninsured but medically necessary surgery next year on my taxes.  I really need to research the specific areas of the IRS tax code and previous legal cases that permit this, just to prevent some ignorant person from trying to tell me it's not permitted.  The AMA and WPATH position statements make it clear these surgeries are medically necessary when WPATH requirements for surgery are followed.  Of course, there's always some ignorant fool somewhere that will try to make things difficult.

So, does anyone know if electrolysis falls under this same IRS topic?  It would certainly be great to claim some percentage of my expense as medically necessary but uninsured.

[regan]

I will certainly be claiming the $2500 expense of my orchiectomy (and travel and lodging expenses, if possible) as an uninsured but medically necessary surgery next year on my taxes.  I really need to research the specific areas of the IRS tax code and previous legal cases that permit this, just to prevent some ignorant person from trying to tell me it's not permitted.  The AMA and WPATH position statements make it clear these surgeries are medically necessary when WPATH requirements for surgery are followed.  Of course, there's always some ignorant fool somewhere that will try to make things difficult.

So, does anyone know if electrolysis falls under this same IRS topic?  It would certainly be great to claim some percentage of my expense as medically necessary but uninsured.

Apparently all transition related expenses are deductible as "medically necessary"...

http://www.huffingtonpost.com/joanne-herman/transgender-surgery-is-of_b_447472.html

[Caith]

Here is the actual document (PDF file) of the decision from the US Tax Court:
http://www.ustaxcourt.gov/InOpHistoric/ODonnabhain.TC.WPD.pdf

[Caith]

So, does anyone know if electrolysis falls under this same IRS topic?  It would certainly be great to claim some percentage of my expense as medically necessary but uninsured.

The IRS Tax Court document cited above seems to clearly indicate electrolysis is excluded as a cosmetic procedure. Bummer.

[Michelle.]

I have the sinking feeling that the cost of SRS and two years or so of premiums are probably about the same in cost.

The above assumes that somewhere on the free market is a plan that covers everything. Than again that type of plan costs a lot. Example a go anywhere PP0 costs more than an HMO. The PPO may be four times as much as your workplaces lowest contracted plan.

So either way your out a good 20k to have SRS.

The way I look at this.

Would I rather drive a new Cadillac or have a Cadillac pu$$y?
I think I drive a used car or take the bus the next few years. Or get a loan if needed.

[Medusa]

"Luckily" I live in EU and have it covered with public health insurance (which cost 13,5% of full income and is compulsory so it will be very displeasing to not have it covered)

[hilah.hayley]

CIGNA is a major supporter of transgender medical needs, including surgery.  While my employer's health insurance charter explicitly excludes transgender therapy, medications, and surgical procedures, CIGNA is their claims administrator and has not denied any of my therapy, psychiatry, or monthly hormone claims.

Caith,

I too have Cigna and they are thankfully covering all of my Surgeons fees, hospital fees and anesthesia fees!! I'm incredibly thankful and consider myself quite lucky, since my company had Guardian as a carrier last year. I'd gotten approval from them for SRS but it was never going to happen. They were simply playing games with me. In January, we switched to Cigna and at first I was very very nervous about the coverage. It turned out it was blessing in disguise!