I had insurance on my Father's pan w BCBS....they did not cover SRS. Yesterday, however, I switched to my employer's insurance - Oxford which is part of United Health. I am planning my SRS and have been discussing it with my incredibly supportive employer...My boss helped me get onto insurance right away, but she is not sure if our plan will cover SRS. She has been incredibly busy and we haven't been able to confirm that plan specific right now, but she told me I will have my member id card in 10 days at which point I can contact the provider to see if they will cover my surgery. She looked up United Health's protocol for GID and they promisingly have this new policy in effect: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Gender_Identity_Disorder_CD.pdf

It states that most standard plans cover therapy, hormones, and testing...but not surgery. It then states that some other plans do cover surgeries. I can only assume that my employer has a standard plan with them, thus that SRS won't be covered. I work at a store in NYC that is very successful but still a small business. I don't imagine I can convince them to change their policy for just me when it isn't a big company. I suppose it is possible that srs will be covered, but being real - it is very unlikely. I will contact next week to find out the specifics.

My question is, do I have any hope of getting around this surgery exclusion with them? I don't even know if I have been diagnosed with GID - my doctor at the tg clinic I go to uses a different, less "stigmatizing" diagnostic code of endocrine disorder. Is that a good thing because I won't have an old diagnosis, or a bad thing because I won't have a history of GID? Or does it not matter as I have been in treatment on HRT for 9  months and seeing my Dr at the clinic for 1 year...SO many questions...I don't know what I will do to afford this surgery but I need it as many of us do and will continue to figure it out. Any guidance would be much appreciated!

Di,

I think they use the code for endocrine disorder for the insurance billing because so many are not transgender friendly and that way it wont be questioned. As far as workarounds to pay for surgery I don't know if there are any loopholes for surgery but honestly haven't looked very hard yet.

As far as not having an official diagnosis of GID it is most likely to cover you insurance wise and prevent denial of benefits. I wouldn't worry about it too much especially since I believe that you said the same place/doctor has been giving you a prescription for hormones for nearly a year.

To cover the cost of surgery i've only found a few options
1. Save the money
2. Borrow against 401k
3. Take out a loan for medical costs. Found a few places online
4. The riskiest is to borrow against your home if you own one
5. Ask for "donations" from supportive family

Don't worry be happy......

Thanks for the response...

I have an update actually...I just talked to my insurance company as I received my number and they told me that SRS would not be covered. I asked if there were any specifiic exclusions to srs or transgender treatment and they said no...So what do you do when your plan doesn't even mention GID or SRS etc?? Is this potentially good news as there is no specific exclusion, or is it just as bad as if there were one?

I would consider it a good thing because other than srs surgery they are saying other treatments are covered since they are not specifically excluded hormones, therapist, etc.

Personally I am just starting my journey and haven't even got to the hormones part yet but I think that is good news to have. There are insurance policies out there that exclude all of it.

Yes...but this was an agent telling me it was not covered, but that it was also NOT excluded...so could SRS potentially get covered by them if it is deemed medically necessary by my Dr? They don't exclude it...

Sorry i'm not sure i can answer that. Perhaps someone here has the same insurance and an answer for you. It is a good question and raises a valid point if they say it's not excluded.

Yes. I have heard of people who have been able to have their doctor help them make the case that it is medically necessary, and therefore was covered on insurance. This is definitely an option worth pursuing. I am not sure what the process is, but you might want to contact them and say "I want to get preauthorization for medically necessary SRS and want to know the process for doing this" and see what they say. Even if they say it's not covered, tell them you want to make a formal request and need to know the process. They may require you to have your surgeon or doctor submit the preauthorization request.

I think this is worth a try personally.

As a second (concurrent), your employer can contact your insurance company and ask how much it would cost to have a trans-inclusive plan. NCTE has shown through several case studies that the cost of covering trans people is very very small (pennies per covered person per year). I would ask your employer to inquire about having your plan be trans inclusive, and find out the increase in premiums they would need. If it's a high cost, I'd reach out to NCTE and ask for any information they have that can help with the negotiation.

You can also request the exclusions list yourself and see how the language reads. If it doesn't say anything about trans surgery not being covered, then you certainly have a shot at making a case on medically necessary grounds. Most insurance companies will require two evaluations by psychologists recommending medically necessary SRS after GID (GD) diagnosis, and your medical doctor may also need to write a letter recommending SRS as medically necessary and appropriate for you.

If you come armed with this you have a much better shot at getting it approved on any appeal.

While we're on this topic

You can write off expenses for SRS (and HRT and other medically necessary transition expenses) from your taxes. The IRS has ruled that SRS, and medically necessary breast augmentation, as well as HRT is allowable. Read more. Also covered, transportation to and from doctors appointments, transportation and lodging related directly to surgery (i.e. flight to Thailand, and hotel while you are there). If you do this make sure you keep all reciepts itemized, and make sure they are in your legal name. All must match.

Because of the above, you can also apply money from your Flexible Spending Account at work (FSA) to apply towards surgery (I just did this). You can make the maximum contribution to your FSA (currently $2,500)  in your surgery year and then submit the necessary documentation to your plan for reimbursement. You will require a form from your doctor (provided by the FSA administrator) that the SRS was medically necessary. The rules are the same as above. You can use these funds also to pay for travel to and from surgery, and lodging related directly to recovery (do not combine your medical trip with any 'vacation' as this makes things much more tricky). I personally was reimbursed for my flight to Thailand, and my hotel while I was there - saving me several hundred dollars off my taxes.

With planning and research there are things you can do to reduce your costs even if your health insurance does not cover the surgery.

Quote from: PrincessDi on May 09, 2013, 10:19:43 AM
Yes...but this was an agent telling me it was not covered, but that it was also NOT excluded...so could SRS potentially get covered by them if it is deemed medically necessary by my Dr? They don't exclude it...

Probably not. It's up to your company... not the insurer to decide what they want to cover and not cover. Your company can have a policy written with pretty much any sort of coverage written in to the policy... if they are willing to pay for it. If they want to include snake bite coverage, tiger bite coverage, or getting trampled by wild elephants along with anything else they wish to pay for, they can have it covered. When your employer re-news their insurance contract, every year or 5 fives, whatever the term is, they can specify to add additional coverages, and they will have to pay for them... meaning an increase in your and every other employees monthly premium. The percentage of trans employees (especially at a small company) is incredibly small, and the increase in cost of covering SRS will be relatively high in perspective to it's need, so most companies opt not to cover it. Those that do are usually very large, and in the Fortune 500 listing. These companies are large enough to absorb and defray the costs, also they are more socially image conscious as well. They don't want to look bad by denying SRS coverage either.