Hey all, I'm wondering if I can get some input from those who used insurance for their top surgeries...I'm one month on T and only just starting to research the nut-and-bolt specifics of top surgery; I'm having a hard time finding specific info on Transgender Healthcare plans.  I was on Humana through the Affordable Care Act last year, and it's time to re-up, does anyone have any recommendations for good companies/plans that helped them cover their top surgery? (located in Texas)

I'd also like to hear how people got the ball rolling with their healthcare/insurance companies. Thanks!

Luck is all I can say.  I been researching trans gender surgery being paid by insurance since August.  There's a few who get lucky when their employment's insurance pays for it or, like where I live, Medicare paid for it - but they went through long struggle/battle.  I am not on medicare so that excludes me. 

I research states that require insurance to cover tans gender surgeries, and ha! no surgeons live in the area.

Soooo I think California may be best place to be if you're TG and need insurance to pay for it... as there are plenty of SRS surgeons there and its required for insurance to pay for it. 

Good luck

ACA policies don't necessarily cover this, probably do not. However, there are exceptions all over the place, so call your insurance company. Look at the policy first and see if there are any exceptions, and if "->-bleeped-<-" is one of them. If it is NOT then you have a start. If you are in 5 states, there are laws preventing blanket exceptions for it (California, Colorado, Mass.?). That doesn't mean they absolutely WILL cover it, but that they have to cover for medical necessity, which they determine. Good luck.

--Jay

Not to hijack, but I definitely need insurance advice myself. Does anyone know how to actually go about figuring out what one's specific insurance plan covers? Do I need to call someone? Is there a form I should be looking at? (I'm on UMR/UnitedHealthcare and trying to figure out about top surgery coverage, as my preferred surgeon does accept insurance.)

Help a small child out. This is the first time I haven't just gone running back to mommy and daddy, and I'm, uh. Overwhelmed is putting it mildly.

Quote from: captains on November 25, 2014, 02:30:16 PM
Not to hijack, but I definitely need insurance advice myself. Does anyone know how to actually go about figuring out what one's specific insurance plan covers? Do I need to call someone? Is there a form I should be looking at? (I'm on UMR/UnitedHealthcare and trying to figure out about top surgery coverage, as my preferred surgeon does accept insurance.)

Help a small child out. This is the first time I haven't just gone running back to mommy and daddy, and I'm, uh. Overwhelmed is putting it mildly.

Captains, not looking good for you. This links to a PDF: 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

Quote from: captains on November 25, 2014, 02:30:16 PM
Not to hijack, but I definitely need insurance advice myself. Does anyone know how to actually go about figuring out what one's specific insurance plan covers? Do I need to call someone? Is there a form I should be looking at? (I'm on UMR/UnitedHealthcare and trying to figure out about top surgery coverage, as my preferred surgeon does accept insurance.)

Help a small child out. This is the first time I haven't just gone running back to mommy and daddy, and I'm, uh. Overwhelmed is putting it mildly.

Every insurance plan has different policies, the company doesn't matter.  You need to call the benefits number on the back of your insurance card and they can give you specifics for your insurance.  Additionally, they may have a website where you can look the information up.  Even if you find that though, I would definitely still make the call to the insurance company, just in case.  They should be able to tell you step by step what you need to do.  Again, what is most important is note that the company doesn't matter, it is the policy that does.  Follow what they say to do to the letter so that they cannot give you a problem on payment.

Welcome to adulthood!  Good luck.

Actually my reading of the plan was that they DO cover top surgery, but only after 3 months of therapy. Not a real long time as therapy goes. However, some people don't really feel they need the therapy. (Weird things not covered, btw, "self-injected hormones" (weird) and Lupron. Kind of mad about that one, trans kids need this one, but kind of off the subject.

--Jay

Be aware that when you call and they happen to say it is covered the people on the phone could be spouting BS and when they look at the exclusions on your policy you could be out of luck.

Unless you live in a few states, they will almost certainly deny you the first time around. Be prepared for that. It is the BS refusal that basically means this: "If we deny you the first time around odds are good you won't bother us again."


--Jay

Quote from: Alexthecat on November 26, 2014, 04:37:03 AM
Be aware that when you call and they happen to say it is covered the people on the phone could be spouting BS and when they look at the exclusions on your policy you could be out of luck.

Quote from: Brett on November 25, 2014, 08:28:47 PM
Welcome to adulthood!  Good luck.

In WA the state attorney's office said tg services cannot be excluded. I called the 800 number for customer assistance, they confirmed that surgeries are covered and for me to call back after the 1st and ask to talk with the transgender specialist...she is going to guide me step by step to SRS (and BA, if I want it--that's covered too (only for mtf ts). I was told they follow the latest SOC for tg people.

I am currently winding my way through the maze of insurance coverage, myself.  I am lucky to live in Oregon AND be a public employee, which means insurance companies can not have transgender exclusions.  That luck/privilege extends further because my health insurance actually will pay for top surgery (and other gender confirming surgeries), but there are hoops.  Lot of hoops.

Step One: Call the Member/Benefits Services number on your insurance policy card.  If they say that gender confirmation surgeries (they may still use the older language of sex-reassignment surgery) can be covered, ask for them to send you the documentation that outlines all requirements for obtaining approval.

For example, my insurance company requires FTMs to be on continuous (any break in HRT is seen as a lack of commitment to transition and is grounds for denial) T for at least a year, talk therapy (with someone with a doctorate, not necessarily just a licensed counselor) for at least 1.5 years, and living as a man in all realms of life (socially and work) for at least a year.  In addition to the letter written by my therapist for hormones, I also must get an updated letter from my therapist plus a letter from my primary care doctor AND the surgeon who I choose to perform the surgery.  There is a huge list of all the details required to be in the letters, as well.

Lots of hoops, and since I've only been on T since September, my top surgery will be no sooner than the fall/winter of 2015.  But paying around $1000 for the surgery (instead of $9000ish) is worth it to me.  And my hope is that the more trans people make themselves known to insurance companies, the sooner the insurance companies will loosen their death grip on their "Prove that you really want it!" mentality.

My policy started covering trans stuff only this year, and they didn't have any handle on it a couple of months ago when I started calling for information. I was told that trans surgeries are covered (I already knew that), and the nice lady read every single syllable of the wording in a few different sections of the coverage document (I had already read them) and then referred me to my benefits office for an Evidence of Coverage document that I think I've already accessed. I need to start printing out these documents and keeping track of what I have and whom I have called.

I guess my next stop is to actually call the benefits office and ask what to do next, sheesh. I'm thinking that if I want hysto covered in one year, I had better start getting my ducks in a row NOW. At this rate, I might need to wait even longer than I had anticipated.

You can get specific information by calling the number on your insurance card and asking, but you should be able to get online access to a very large document that explains exactly what is covered and what basic hoops you have to jump through. Your card should have a URL, and once you have established login access, you will be able to get direct access to the document. But it likely won't tell you whom to call or precisely where to start.

You might have to do a lot of digging, but stick with it. Keep track of which numbers you call, the people you talk to and which department/division they work in, and the documents you have at your disposal. That way, if someone says, "Oh, you need to start with the Evidence of Coverage document," you can say, "Yeah, I've already done that, and it doesn't tell me whom to talk to or how to get started. That's why I'm calling YOU. If you aren't the right person to talk to, please transfer me to someone who can help." Or whatever.

Anyway, that's my two cents' worth. Or a quarter, adjusted for inflation.

I know I'm ->-bleeped-<- out of luck in the surgery department, but I don't know if hormones are covered. Oh well, it happens I guess.

I get surprised when people say they got a good part, if not most of their surgeries covered. How I envy you people!