Anyone know anything about how ACA (obamacare) will change trans health care coverage?

I just got a big packet in the mail from my insurance company about choosing a new plan because they had to overhaul everything to meet upcoming ACA requirements.

I am self-employed and purchase my own insurance. The new plans all have better coverage but are more expensive, as expected. That's okay of course, I'd rather have more coverage even with an increased cost - especially if they will cover trans related stuff, or at least some of it.

I have been digging around trying to read stuff how about how ACA requires insurance companies to cover stuff related to gender identity, but no idea how this will work out in practice. Maybe just plans under the health exchange?  I know basically nothing about any of this.

Anyways - I have to pick a new plan by November. If trans stuff is covered now, I will get a plan with a lower deductible and pay more monthly. There just seems to be so much unknown about the policy changes at this point by everyone involved, so I am not sure what to do.

I am pretty sure if I called up customer service to ask them this they would be more clueless than I am.

yeah, totally replying to my own thread - but it seems that maybe the gender identity discrimation prevention just means they can't deny medical care because you are trans (like gyno appointments, etc), not necessarily that they can't deny trans health care like hormones and surgery? So confusing.

Well maybe the best clues are from Medicare, which isn't quite the same as it is a single payer system and Affordable Care Act (ACA) is not. However, not sure you know how this works but each state must set up exchanges (and if the state refuses the federal government sets one up for them). The insurance companies in the exchange must follow general practices such as not refusing pre-existing conditions and so forth. The ACA is more insurance reform than health care reform in some ways, so it puts limits on health care companies and one limit could be what they must cover.

I believe once people on Medicare can get coverage then it's going to be pretty hard to not cover them under the ACA. There's nothing in the Affordable Care Act guaranteeing coverage to trans people but nothing forbidding it either.

So what gives? Well my understanding is that Medicare does not now nor never had covered SRS (though I know that people are getting stuff like hormones, labs, etc.) They are also taking transgender under advisement, but I don't know yet when they will reach a conclusion. The other thing that their have been law suits against medicare. The relationship of Medicare to the ACA is very interesting and one to watch. And I think they are tied together under the whole discrimination aspect.

Specifically under the ACA, the Dept of Health (I think) is interested now in all cases of discrimination against people who are LGBT (fully including the T here). I'm going to look for this site, as it might be useful to us now.

So though things are moving in a positive direction, they might not be moving so fast.
BTW, though I am on medicare, I just started on this about a month ago. I haven't attempted to get any sort of coverage, but I know currently what the coverage is, at least for top surgery (not yet).

BTW, you should be able to qualify for various waivers for income. The initial price for insurance may be the actual cost and not what you would necessarily pay out of your own pocket. I don't know what it is for a single individual as it is always quoted as a "family of 4". I think you qualify for some discounts if your income is under $40,000 as a single person.


--Jay

Thanks Jay - that makes more sense.

Basically - don't expect coverage for surgery, same as before. Everything really is really in a flux right now with health care for sure.

I will probably split the difference and go with the medium level deductible.

I didn't even try to put lab tests or trans-related doctor visits on my insurance because I was afraid they would drop me for it - at least that fear is gone now, so maybe they will cover that sorta stuff at a minimum.

well, a lot of surgeons don't take insurance for SRS anyway. You are expected to pay up front, and then file a claim with your insurance carrier for reimbursement afterwards.

And I imagine if one were to elect to have their surgery outside the country, (Thailand, for example) they would be completely S.O.L., but maybe not.

I don't have anything to add about TG coverage (it's probably going to be a case-by-case thing for every person and every procedure), but I'm just popping in to mention something about the cost.

Maybe I was paying a lot before, or maybe it's because of where I live, but all the quotes I've gotten have said that I can expect to pay $60-70 less than I currently am (for a plan that has so far paid for nothing except a single physical). Also, you qualify for a tax break or a subsidy or something if insurance costs you more than 7% of your income. The Turbo Tax website has some decent information about this that's not company-specific.

Quote from: TaoRaven on September 14, 2013, 06:26:45 PM
well, a lot of surgeons don't take insurance for SRS anyway. You are expected to pay up front, and then file a claim with your insurance carrier for reimbursement afterwards.

And I imagine if one were to elect to have their surgery outside the country, (Thailand, for example) they would be completely S.O.L., but maybe not.

The current regs for surgery (on Medicare) are that it is elective cosmetic surgery. I think the law suits have been to say that it is not elective and not exactly cosmetic. So if they win they will probably have implications for the ACA. But right now... no. I don't think they will drop anyone for being trans (not sure if you have a fly by the night carrier, but no odds on them dropping you for anything). As I said they are takign this all under advisement, so they may be covered eventually. But that also means that you would need to wait for it. I am guessing that I'm better off not trying to wait.

I am quite sure that once insurance covers it, you would have less freedom to choose where you go for it, that means within the US but probably applies to out of state as well, so if there is someone who can do it, you go to them. Might mean you could go out of state in some cases, as I doubt there is a NM surgeon who can do bottom surgery of any sort. I am pretty sure that you don't get covered going to Thailand on the US dollar. This applies to people from other countries who go for surgery in the US as well. A lot of people go to Dr Garramone for top surgery from the UK and other places that have their own national health care. Their governments don't spring for that either. Of course you can still go off your policy or try to get reimbursed later (that might work in the US the same as it does now. But going abroad, that would be unexpected really.

I know of someone who just got covered under Kaiser Permanente in California. He had to go within their network, but they pay, I don't know but a high percentage.

One reason a lot of doctors don't take the insurance is due to the hassle of no doubt being denied repeatedly. They don't want to be in the business of messing with insurance companies who are just going to give htem trouble. Might change if coverage becomes more common.

--Jay

I am in Oregon and we have a State law that went into effect this year that basically requires insurance companies that provide HRT to cisgender people to provide it for us too.  As others have noted the surgery part, despite our issues, is considered cosmetic by most insurance plans.  Trans people will do great here with the ACA

The Affordable Care Act is highly politicized and that is why many States, like Florida, are choosing to "opt out" so no heath care exchanges for those citizens.  Your State of residence and your wealth should not determine your level of health care but here we are........

Quote from: Tessa James on September 14, 2013, 07:19:51 PM
I am in Oregon and we have a State law that went into effect this year that basically requires insurance companies that provide HRT to cisgender people to provide it for us too.  As others have noted the surgery part, despite our issues, is considered cosmetic by most insurance plans.  Trans people will do great here with the ACA

The Affordable Care Act is highly politicized and that is why many States, like Florida, are choosing to "opt out" so no heath care exchanges for those citizens.  Your State of residence and your wealth should not determine your level of health care but here we are........

It's possible I am wrong in this, but I think that the state must have exchanges under the ACA and if they don't do it the federal government does it for them. The trouble is that there is federal money for low income people. The state can opt out of providing assistance to low income people. This must be done by Jan. 2014. Some states already have the exchanges up to look at, though what you actually pay may be less. If you are in a state that doesn't take the medicaid funding, I think you pay full rate. Though I could be wrong on that one.


--Jay

Jay you are likely correct about that.  I am working with our County Health team setting up the exchange here called "Cover Oregon."  It was my understanding that the States that opted out left considerable funds "on the table" for others but would need to verify that.  I do know that this is a sort of social experiment with the States being able to innovate and provide alternatives.
Ideally, IMO, we would have a single payer system and eliminate some of the profit and avarice from care.

I consider the ACA a step in the right direction and insurance reform but not yet health care reform.

ACA makes denial based on "preexisting conditions" a thing of the past as is any discrimination (different rates) based on legal gender but plans can still have exclusions for things, trans* care included (most notably surgery).

The problem even if surgery was covered comes with reimbursement rates to the doctors for the procedures. Private insurance might pay enough that a surgeon will choose to participate in a company's network but federally CMS (Medicare/Medicaid) rates don't cover squat which makes "insurance for everybody!" a moot point if nobody but a few overworked hospitals accepts the lower end plans or any Medicare/Medicaid plan at all.

Not mentioned is the cost of the "insurance;" I've seen a quote in CA for $23,000/year and that's with such BS as $40/ office visit deductible (limit 3 visits year for preventive care) and $50 meds.

Quote from: Flan on September 15, 2013, 04:27:58 AM
Not mentioned is the cost of the "insurance;" I've seen a quote in CA for $23,000/year and that's with such BS as $40/ office visit deductible (limit 3 visits year for preventive care) and $50 meds.

I would suggest you do more research as this is a complete departure from anything I've seen. I'm also in California.

@Tessa--
Yes, was my understanding re: the set up of the exchanges. Say Texas (not to pick on you Gov Perry!) but they will have an exchange, what I don't know is whether there will be any medicaid funding at all. He opted out of this for his state (not much of reform, but that was the Supreme Court not the ACA). So that the assistance you would get if you make less than $40,000 K might not be there. And for sure low income people will not. So in some states they will be much more likely to get insurance than in others.

The ACA is definitely health insurance reform (and not all that drastic either--- in most countries with extensive private insurance, the insurance is not-for-profit, like in Switzerland, which has a similar system I think). Some states have not for profit insurance, I think the biggest of these is Kaiser (CA).

@Flan-- well the surgery denials might come more "creatively" that's true. But there are states (like CA) where it might become illegal. The reimbursement rate for hospitals and providers is likely not to get better, I got medicare C&D which of course i pay for (it's way way cheaper than what I paid while I worked in the public schools, though of course my income isn't as high). Which makes me have more flexible coverage, and doctors more likely to take my coverage. I think that there will be a lot of people with bare bones type coverage. And I think you are right that there will be plenty of doctors who will say they can't do the surgery at that rate. I don't think you can call it "insurance for all". I think "health insurance reform" would have been a better name for it. I don't know where those figures like $23K for insurance come from. I'm on the CoveredCA website http://www.coveredca.com/
Depending on your income a "bronze plan" (coverage somewhat like you are describing) average for everyone rates (from 25-60 years old) are like $230/mon which is no assistance and I am guessing one person.  You are likely to qualify for assistance which can be 80% of the cost. There is also coverage under medicaid that is over the poverty line or if you have pre-existing conditions. Odds of getting anything except perhaps hormones and labs would be 0%. @Lo is correct.

BTW, just want to say, I have nothing at all to do with any of this stuff. I'm not a paid person or anything.

@Tessa--I think that's one of the better things about the ACA, is the ability of states to innovate.


--Jay

I was probably being way too optimistic about surgery coverage. I know someone like Garramone would never take it anyways - reimbursement would just mean I'd have to save it anyway. Oh well. The pre-existing condition thing is great though. I lucked out and got insurance before I was diagnosed as bipolar. If I had gone the other way around, I would have been straight up denied. No longer the case.

For context on pricing changes since it was mentioned in this thread - my plan used to be $129 a month for a 10k deductible, no prescription coverage, a limited number of co-pay doctor visits, and dental.

The cheapest plan I can get under the new system from the same insurance company is $248 for a 5k deductible (in-network), no co-pay visits,  prescription coverage, mental health coverage, vision, and dental. I live in WA state. My insurance company is a branch of Blue Shield.

Do you have to stay with your current provider? I have to switch because Aetna is pulling all of its personal plans out of CA next year (totally -not- a big corporate tantrum) and I have to go shopping anyways. I'm currently paying $235 with Aetna, with a deductible in the area of $2-4000, and I'll be switching to HealthNet for the "Silver70" plan at $175/mo with a $2000 deductible. According to TurboTax I qualify for a tax credit too.

Quote from: Lo on September 15, 2013, 04:04:33 PM
Do you have to stay with your current provider? I have to switch because Aetna is pulling all of its personal plans out of CA next year (totally -not- a big corporate tantrum) and I have to go shopping anyways. I'm currently paying $235 with Aetna, with a deductible in the area of $2-4000, and I'll be switching to HealthNet for the "Silver70" plan at $175/mo with a $2000 deductible. According to TurboTax I qualify for a tax credit too.

I don't think so, though I have no idea what the situation is if you are covered by your employer, but since you have a private policy? Maybe someone else.

@spacerace--I am going by what's happening in medicare. But there are some differences in that medicare is a single payer.
I doubt Dr G would ever take insurance because he is famous and doesn't need to. People are going over from England with NHS and Australia with I think they call it medicare, and paying him out of pocket. So why would he? He does give you a letter where you can apply after surgery but he doesn't do anything else. He doesn't need to. I am imagining that local people-- like there is a guy here who does them. He does some local guys and he will take insurance. That's what's happening with Kaiser too for another guide to how things are going. You won't have choices so much. If you want them you go out of pocket.



--Jay

Quote from: aleon515 on September 15, 2013, 05:27:46 PM
@spacerace--I am going by what's happening in medicare. But there are some differences in that medicare is a single payer.
I doubt Dr G would ever take insurance because he is famous and doesn't need to. People are going over from England with NHS and Australia with I think they call it medicare, and paying him out of pocket. So why would he? He does give you a letter where you can apply after surgery but he doesn't do anything else. He doesn't need to. I am imagining that local people-- like there is a guy here who does them. He does some local guys and he will take insurance. That's what's happening with Kaiser too for another guide to how things are going. You won't have choices so much. If you want them you go out of pocket.

Yeah - I don't mind going out of pocket for Garramone. I've paid for everything related to transitioning, including months of therapy, without being able to put it on insurance. In the magical land where insurance had to cover stuff though, I figured it was worth investigating.

Oddly, I am actually pretty against the nationalization of health insurance at an ideological level. However, our system is so warped at this point by the collusion of insurance companies and the government that everything is really FUBAR, and the best solution is not really possible anymore. As such, I figure why not take advantage of what is in place if I am paying for it anyways.

I had years and years under this pre-existing condition thing. I would technically have insurance but it ended up never covering what I needed it for. Therapy is one of those things that gets low (or no) coverage.

Dr. Garramone (and other "super stars") don't need to take insurance. It's one of those things that is just a headache for him. If you have people flying from all over the world to see you what possible motivation could he have.

Going to stay away from the political arguments as it's pretty hot button and could get locked REALLY fast.

--Jay

The subsidies are on a sliding scale and end once your household income reaches 400% of the federal poverty level. So unless you're fairly affluent you should get some degree of assistance with your premiums (unless you're really poor and live in a state that refuses to expand Medicaid, in which case you don't have many options but won't face the tax/penalty for not having coverage).

I don't have a link, but apparently the IRS confirmed that transgender care is tax deductible. At least there's that.