In June, I stopped going to the low-cost clinic and started seeing my GP for hormones. My new plan is kind of strange and has three tiers. I don't pick a tier; I move in and out of them, depending on what kind of care I'm getting. I thought I had the tiers all figured out until I received a bill for the GP visit. I figured that it would be covered eventually, but then I received a second notice and paid it, thinking that I must have been mistaken about how the plan works.

Then I received a belated denial of coverage from the plan itself. No reason given--just that these services were not covered. WTF? I called the insurance company. After a protracted hold, I was informed that my doctor had put "unspecified" for the services and should have been specific. The company would get in touch with the office, clarify the reason for my visit, and get back to me.

This is a trans-friendly plan, so I knew that it would be smooth sailing as soon as my purpose was clarified. But then I got the follow-up call. The nice lady said that the visit was not covered; she used some terminology that I didn't quite catch. I said that I still didn't understand, and she then said that trans-related services are specifically excluded on my plan.

Adrenaline spiking, I instantly became a barracuda. "How is that possible," I snapped, "when such exclusions are ILLEGAL in California, and I specifically chose this plan because it DOES cover trans-related care?" I couldn't stop myself. At least I wasn't truly rude.

She put me on hold for several minutes and then came back, nice and solicitous. My bill had been denied because the visit was "unspecified," and everything was fine now because they had the reason for my visit, and I should always tell my doctors to be specific, blah blah blah. Reimbursement forthcoming.

My sense of panic during those minutes was overwhelming; I saw my entire future of surgeries (hysto and a multi-stage phallo) crumbling before my very eyes. I took quite some time to calm down afterward.

Now that I have calmed down, I'm trying to figure out exactly what happened. Will I face an initial denial every time, or was this woman confused about which plan I was on? All Blue Shield plans in California have to cover trans stuff now; maybe she was at an out-of-state call center and got confused. On the other hand, this plan covered trans stuff even before the law was passed. It's all very weird, and I'm still a bit confused.

OMG!  I just emailed my insurance company which happens to be anthem blue cross shield out of california and they said I only had $10,000 coverage for trans related surgeries.  I almost lost my mind.  I re read my policy and it says up to $10,000 for travel to transition.  So I emailed back and wanted specifics, because I thought how could you put an amount on surgery when I am covered for any major surgery?  Still waiting for a reply, but I think I will be calling to get clarification.   And like you I chose this plan specifically.  I have my hysto scheduled in January and bottom surgery scheduled for July.  Hoping to get this clarified soon. I even gave them the policy which is here:

http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051166.htm


I need some answers!!

Good luck.

Ten thousand barely covers top surgery. They must have it wrong.

My lifetime coverage used to be $75,000, but I think it went up. I'm not sure whether travel is separate.

At least you have specific guidelines. I still have to hunt mine up. I would also feel better if I had the name of a liaison, either a university employee or an insurance company employee.

I'm glad I'm not the only one having little heart attacks about this sort of thing. I'm extremely lucky to have this coverage, and now that I expect the coverage, I absolutely will not take no for an answer.

Any idea when you will hear back?

You live in Cali & have blue shield? So do I.

Blue shield flatly denied my therapy related claims and gave me the runaround over and over again when I called them. I finally had to contact the state department of insurance and file a dispute. Apparently they had a problem because I had used a out of network provider instead of their own mental health department. When I put transgender into the search box in their website nothing came up so I had no way of knowing that!

They finally grudgingly paid my claim but told me it was on an "exception" basis.

It seems to me that blue shield intends to put many barriers up for transgender people. I expect that every claim you file will get denied for some reason and you'll have to fight them.

Quote from: Alex55 on August 17, 2014, 01:33:05 AM
OMG!  I just emailed my insurance company which happens to be anthem blue cross shield out of california and they said I only had $10,000 coverage for trans related surgeries.  I almost lost my mind.  I re read my policy and it says up to $10,000 for travel to transition.  So I emailed back and wanted specifics, because I thought how could you put an amount on surgery when I am covered for any major surgery?  Still waiting for a reply, but I think I will be calling to get clarification.   And like you I chose this plan specifically.  I have my hysto scheduled in January and bottom surgery scheduled for July.  Hoping to get this clarified soon. I even gave them the policy which is here:

http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051166.htm


I need some answers!!

Good luck.

Hey, Alex.  I looked through your policy, but couldn't find any information on the coverage limitations when it comes to cost?  You definitely want to investigate further.  Insurance companies will try to find a way to meet the mandate of providing for trans related care, but not cover all costs.  One guy posted a policy here that said that they would only cover the first stage of phalloplasty, with really clear directives as to what parts of the surgery they wouldn't cover (like making the glans, for example). 

I would suggest being really sure on how much money you will get total towards your surgery.  Make sure you go in-network or you will have a higher copay (or they won't cover it at all, depending on your plan).  Also, look to see if the amount they will pay is lifetime or annually.  If they say $10,000 per policy year, put each surgery out by a year to get all the money you can.

I am sorry they are jerking you both around guys, that sucks. 

Insurance companies are butts.

Quote from: Eva Marie on August 17, 2014, 08:35:16 AMIt seems to me that blue shield intends to put many barriers up for transgender people. I expect that every claim you file will get denied for some reason and you'll have to fight them.

Eva Marie, are you saying that your therapist identified the reason for your visits as trans-related? And Blue Shield (no accident it abbreviates to BS) expects you to choose in-network therapists? (Also, are you on an HMO or a PPO?)

My therapist did not put GD or anything trans-related in the box, and I was extremely wary of having any such information on my paperwork, so I will remind him never to release it. However, he says that his visits are covered at 50%, and HE is the one who called them--in advance--to set all of this up. I'm waiting anxiously to receive a 50% reimbursement for the whole year going back to February 1.

I am not married to this plan, but my old HMO was replaced by what I considered to be an inferior plan. So I'm trying out the PPO. I haven't fully researched either the new HMO or the PPO I'm currently on. I need to look into both before open enrollment this year--otherwise, I might have trouble getting hysto in December 2015. I hate that open enrollment is so close to my proposed surgery date, so I really need to have my insurance nailed down this year. But it is what it is.

My therapist thinks that PPOs are better for transition unless your preferred surgeon is in the network. I do not have enough information, so I have no opinion. I plan to do some phone-calling and fact-gathering in the next couple of months.

QuoteInsurance companies are butts.

Yes, well...

Quote from: Arch on August 17, 2014, 01:29:24 PM
Eva Marie, are you saying that your therapist identified the reason for your visits as trans-related? And Blue Shield (no accident it abbreviates to BS) expects you to choose in-network therapists? (Also, are you on an HMO or a PPO?)

My therapist did not put GD or anything trans-related in the box, and I was extremely wary of having any such information on my paperwork, so I will remind him never to release it. However, he says that his visits are covered at 50%, and HE is the one who called them--in advance--to set all of this up. I'm waiting anxiously to receive a 50% reimbursement for the whole year going back to February 1.

I am not married to this plan, but my old HMO was replaced by what I considered to be an inferior plan. So I'm trying out the PPO. I haven't fully researched either the new HMO or the PPO I'm currently on. I need to look into both before open enrollment this year--otherwise, I might have trouble getting hysto in December 2015. I hate that open enrollment is so close to my proposed surgery date, so I really need to have my insurance nailed down this year. But it is what it is.

My therapist thinks that PPOs are better for transition unless your preferred surgeon is in the network. I do not have enough information, so I have no opinion. I plan to do some phone-calling and fact-gathering in the next couple of months.
Yes, well...

I always choose the PPO from my company (instead of getting the HMO).  I think the extra cost is worth it.  You don't know what can of specialist/physician you may need in the future and don't want to not be able to go to a certain person because they aren't on your list.  I think it is a really good idea if a person hasn't started gender related therapy yet (and they want to, or need to) and want to be able to find a gender therapist.  There are only a few out there and they may not be in your network.

Quote from: Arch on August 17, 2014, 01:29:24 PM
Eva Marie, are you saying that your therapist identified the reason for your visits as trans-related? And Blue Shield (no accident it abbreviates to BS) expects you to choose in-network therapists? (Also, are you on an HMO or a PPO?)

Arch-

I am on a corporate PPO Blue Shield plan. When I was seeking a therapist I spent some time on the Blue Shield website searching for information about coverage for transgender treatment and I found nothing. I assumed that they would reimburse me for an out of network therapist the same as they reimburse for other out of network providers, at a lower rate than in network - wrong. My claims were flatly denied.

My therapy was clearly noted for gender dysphoria - I did not try to hide it.

I called the number on the card several times to try to figure out what happened and I got a different story each time I talked to someone. Their own representatives could not agree on what happened, and I could not get them to move off of dead center. They were very good about sending out lots of pestering letters asking for all kinds of irrelevant medical records that no one had, such as medical intake records (really? i didn't check into a hospital!), and they used the lack of those records as the basis for denying my claim. I saw this as a deliberate attempt to ask for records I could not provide in order to deny my claims. They finally pestered my therapist enough for these records that she wrote them some scathing letters on my behalf LOL...... she's got Blue Shield now for her own health coverage and she told me that they are giving her the run around too.

I knew about the California law that said that insurance companies had to cover transgender health so I was perplexed by them refusing my claims.

I finally gave up trying to solve it with Blue Shield since I wasn't getting anywhere and I filed a grievance with the California Department of Insurance. They were very nice and very professional and wouldn't you just know that blue shield adopted a different attitude and settled my claims after I did that?

Blue Shield sent me a letter saying that they had their own mental health division (MHSA, Mental Health Service Administrator) and that going forward I would have to use them to get things covered. I go to a well known gender therapist in L.A. that had managed to get my head on straight about being transgender and I was not about to risk the progress I had made by switching to an unknown therapist midstream, so I've been paying out of pocket since then for ongoing therapy sessions.

All of this started because of their sorry web site that didn't offer any information about transgender coverage when I went looking for it.

I wish you the best of luck in your battle with Blue Shield.

Arch does your plan specifically say you have trans related coverage? and what they will cover?  I received and answer back today, and yes, the $10,000 covers surgeries and travel, that is the maximum they will pay.  I still think it's wrong, how can they put a cap on medically necessary surgeries.  I am so PISSED!! Even if I were to pay my deductible, any surgery medically necessary should be covered on their end 60% according to their policy.  sorry I am not a happy camper...

Wow, this thread is just...amazing. Not in a good way.

Eva Marie, I'm assuming that since I'm not coded as trans, I face fewer roadblocks than you did. Since I see my therapist for many other issues now, trans is only a small part of what we do together. Whatever, I'm glad that your threats bore fruit.

I do know that I'm paying 50% of my therapy because that's how out-of-network coverage works in my plan. My therapist is apparently not one of the guys in the network.

Alex, all of my plan options except for the basic no-frills plan are supposed to cover trans stuff, and the pamphlet I received when I was considering plans mentioned trans stuff. I don't know the specifics. I finally hunted up the detailed booklet and was dismayed to see that "penal implant devices" are mentioned...wow, that's quite a typo for a big organization like this.

I have to be pre-authorized, and I supposedly have to pay for everything up front and then get reimbursed. I don't like that much. The travel alone is $5000, and it looks like that's per surgery. The overall coverage isn't specific; the little paragraph is very vague: "This benefit is subject to the principal limitations, exceptions, exclusions and reductions listed in your booklet with the exception of the exclusions for transgender or gender dysphoria conditions, reconstructive surgery and penal implant devices and surgery and related benefits." Commas, anyone? Well, I don't have much more info than this.

When I go to the coverage chart, no numbers or percentages are listed. It's all very distressing. The maximum coverage is supposed to be quite generous...but what the heck is it?

I dunno. I will have to ask. I'm just not sure whom to ask.

Alex, is your $10,000 an annual or a lifetime maximum? It makes a big difference.

I have lifetime unlimited..maximum benefits.

Quote from: Alex55 on August 18, 2014, 10:57:22 PM
I have lifetime unlimited..maximum benefits.

I'm confused.  Do you get $10,000 every insurance renewal (once per year) or $10,000 total for the amount of time you have this insurance ("lifetime") for trans related surgeries?

Quote from: Brett on August 18, 2014, 11:28:20 PM
I'm confused.  Do you get $10,000 every insurance renewal (once per year) or $10,000 total for the amount of time you have this insurance ("lifetime") for trans related surgeries?

Yeah, I didn't get it, either.

The HMO that I just discontinued (maybe I should have stuck with it) either removed the maximum or removed the annual maximum. I think it was $25,000 per year with a lifetime max of $75,000, and one of those just went up. But I haven't looked into this, so I'm probably talking out of my a$$.

So I finally got an answer from my insurance.  A very nice guy actually called me back and said that I am fully covered and that the $10,000 was actually for travel and other expenses they will reimburse up to that amount.  I knew something didn't sound right.  So, after almost having a nervous breakdown and selling everything I have, I can finally relax about that situation and move forward with my surgeries.

Man, that was the most stressful time for me.  I specifically chose that insurance because it covered trans surgeries, so for them to give me bulls#*t answers really caused me major issues.  But, now I will just move ahead and make sure all my letters specifically say 'medically necessary' and get the pre-authorizations done.  Also, I made sure i wrote down the name of the person I spoke to and the time and his number.  He was very nice and extremely helpful.

Alex

Quote from: Alex55 on August 20, 2014, 10:57:11 AM
So I finally got an answer from my insurance.  A very nice guy actually called me back and said that I am fully covered and that the $10,000 was actually for travel and other expenses they will reimburse up to that amount.  I knew something didn't sound right.  So, after almost having a nervous breakdown and selling everything I have, I can finally relax about that situation and move forward with my surgeries.

Man, that was the most stressful time for me.  I specifically chose that insurance because it covered trans surgeries, so for them to give me bulls#*t answers really caused me major issues.  But, now I will just move ahead and make sure all my letters specifically say 'medically necessary' and get the pre-authorizations done.  Also, I made sure i wrote down the name of the person I spoke to and the time and his number.  He was very nice and extremely helpful.

Alex

Aw, Alex, I am SO glad you got it straightened out.  The stress of it all must have been horrible!  Here you think everything is smooth sailing and then all your plans are threatened! 

Alex, I think you and I were in very similar places for a little while. Not a nice place. But you ARE covered--that's fantastic!

I just called Blue Shield to make sure my annual ICK appointment will be covered even though I am listed as male, and I will probably need a colposcopy later this year--both will be taken care of. The gal I spoke to also assured me that my trans surgeries are covered (she spent about half an hour looking stuff up while I was on hold) and gave me a place to start. I still don't know much, but I know more than I did.

She was a hoot, too.

Great news for both of us!

http://insuremekevin.com/2013/09/15/anthem-blue-cross-releases-transgender-health-plan-benefits/
this website has some useful information in the comments.
do note this part of one comment: "You'll have to move up the food chain because the first level customer service reps are clueless." sending an email is a good way of doing this, it ensure that you get some actual answers, and that the company is held legally responsible for the answers they give. this is the right way of doing it for any company, even the government, when money is in question.
my mom has even once called the ceo of one of the biggest banks in norway just to sort out a problem that one of their workers had caused and nobody of the lower level workers would do anything about.
you need to be firm with these insurance company guys, insist that you are right and they are wrong unless their boss can prove otherwise, don't let them say no, only let the ceo's legal adviser finally convince your own lawyer that the law is on their side. usually it never gets anywhere near that far, because it's a waste of time and resources to quarrel with people who are in the right (even though clueless workers on the lower levels don't know that, and give you a default "no"), and they also have a reputation to think of.
rights have to be fought for all the time, unless one was born with too much money.