This supposedly trans-inclusive healthcare plan is turning out to be a nightmare. I was denied coverage for a routine GP visit a few months ago that included a request for a refill on my testosterone; unfortunately, my insurance coverage is weirdly complicated, so I paid the bill before I fully understood that I should have paid only a copay. I made three phone calls to BS about it and was assured that as soon as the visit was properly coded, my claim would be processed. One gal I talked to actually came right out and told me that the visit wasn't covered because it was for trans-related services (although that wasn't the only reason I went). I barked at her, and she retracted. But then I knew I should be on my guard. I have never received a refund, so I'm gearing up to call BS and inquire about it. This will be my fourth call.

But several weeks ago, I had a gynecologist-ordered ultrasound (two, actually, in the same visit), and I have just received a bill from the clinic. I looked up the usual cost of these procedures and determined that this bill is the full cost and that BS has paid nothing. The letter says that my insurance company has notified the clinic that this is the amount I am responsible for, so I know that the clinic did actually try to run it by BS. It's possible that a simple mistake has been made, but I doubt it. I think that BS has denied coverage because I am trans.

The kicker is that I called BS in advance, asked them to flag my account, and verified that these procedures would be covered. I was, of course, assured that there would be no problems.

No way am I going to pony up eight hundred bucks for this. I'm gearing up for battle. Anyone have any tips for me? If I don't make headway, should I get in touch with my employer's benefits office and complain that the trans-friendly healthcare is a crock of sh**? Should I threaten to report my provider to the state insurance commissioner? Maybe I'm getting a little ahead of myself, but I know that if BS hands me a line of BS, I won't be the least bit rational and won't be able to communicate the problem in a post without several days or a week to calm down.

Get every cent from then you can
And make them issue a formal and public apology
...
You got their care as the result of lies on their part. Take them to court they will bleed money. Courts do not take kindly on fraud and even less kindly on discrimination. Go for it,  make them suffer

Do you have access to a supportive lawyer? At this point, it might be time to drag Blue Shield into court, which they hate, and which might drive them to immediately change their tune.

Go to your employer's benefits office (usually part of HR) and give them all of the particulars.  I've had this same kind of thing happen, and usually, they have inside (within BS) help to straighten things out.  If they don't help you, they can at least give you the name and phone number of the patient advocacy group within BS.  (Every insurance company has to have one of these now, at least from what I've read.) 

If none of that works, THEN get in touch with your state's insurance commissioner.  Usually, they have staff that works with insurance companies to help settle disputes like this.

Best of luck to you!  I know that this isn't easy, but hopefully, you can set some precedents that will help you and other trans to avoid issues in the future.

100% of every use of my blue cross only makes everyone involved scratch their head doesn't matter if its trans related or not. Sometimes I'm supposed to pay the full cost myself until I hit the $2000 deductible and then it becomes a percentage until I hit my cap. Then they cover everything 100%. But there are some things that are supposed to be 100% covered to begin with. No one can seem to figure it out. I was tempted to look into Obamacare, but the deadline for my current insurance came up WAY too quickly.

Quote from: awilliams1701 on December 24, 2014, 12:00:22 PM
100% of every use of my blue cross only makes everyone involved scratch their head doesn't matter if its trans related or not. Sometimes I'm supposed to pay the full cost myself until I hit the $2000 deductible and then it becomes a percentage until I hit my cap. Then they cover everything 100%. But there are some things that are supposed to be 100% covered to begin with. No one can seem to figure it out. I was tempted to look into Obamacare, but the deadline for my current insurance came up WAY too quickly.

Yes, exactly. I think that this ridiculous "tiered" policy is just a way to add obfuscation to the equation and make clients uncertain about how much they are paying or should be paying. So BS winds up with more money. But I'm supposed to pay a $20 copayment for in-system general practice visits even before I make my deductible, and that first visit was a GP visit. The ultrasounds...it was bad enough to have to go through that in the first place, but I also had to tell a complete stranger on the phone, and now I'm going to have to keep outing myself and justifying myself to more complete strangers on the phone. I haven't even called about the ultrasounds yet, but I'm so jaded already. I just don't have the stomach for this right now, but I have no choice but to deal with it.

ElizMarie, I'll talk to Benefits if my phone calls don't get me anywhere. I have to call them anyway about my hysto next year--nobody at BS seems to know how I can go about setting up that surgery. More headaches.

In my case more often than not, I pay nothing while they try to figure it out. Once they figure it out I get a bill for either everything or the co-pay.

I'm so sorry this is happening to you, Arch,  but I think you can win this fight.

My advice:

1) When they say they approve something, get it in writing.  If you can't, always note the name of the person who says it was approved, and the time and date.

2) Lawyer up.   

3) This would make a REALLY interesting news story.  So interesting that BS would never want the story out, especially if it could result in a class action lawsuit.

I hate blue shield - they deny everything. They refused to cover my therapy so I contacted the state insurance people - and suddenly they agreed to pay. I'd say to go after them with both guns blazing!

My brother in-law works for BCBS. He stated that they are told to say No. Over and over again. Eventually they wear you down or there is some magic number of times or prior futile attempts before you get to maybe or yes.

Usually on the EOB, or Explanation of Benefits, there will be code on the line item explaining how they came about with their payout and what you owe. Then on the back or further down is a listing of the codes and their meanings.

And then, there is the just plain F'd factor often applied to any not 'In Network' provider regardless whether you made the maximum out of pocket deductible or not. The 'X' factor is 'Usual and Customary' cost for that service in your area. I learned the hard way about that. The clinic bills like $5,000 and BCBS said naaaaa  $350 is all it's worth!!! WTF    Apparently whatever figure they come up with is based on US Government Medicare/Medicade expense or payouts. Which I guess, having worked for a mil contractor, if every little bandaid to walking across the room charge code is not applied or the wrong ones used you get screwed. All this is months after your rear end is totally raw upon finding out that when you asked the people at the doctors office about authorizations and what not they say "Don't worry... EVERYTHING is covered by insurance" Yeah, as far as they themselves getting paid! Hospitals, same day surgery clinics, anestheologist, etc. It's all on you.

Another hard lesson learned is NEVER do anything without spending a lot of time on the phone with the insurance company, doctors office, and anyone else imaginable. Get names dates and the authorization numbers (if any). For most providers knowing what their tax ID numbers or how their services are billed out under are is a big help.

The company I work for has Aetna but this coming year we're back to BCBS. So far I had no problems with Aetna as far as doc visits, blood workups, and HRT. Everything covered. I have no idea what 'Exclusions' are in this new policy (or even the Aetna one) for trans related anything. In the past it was anything, including therapy! But that was a universal in all the insurance polices I've read over these past 30 years.

As I like to counsel people.. "Insurance companies aren't in business to give away money. The idea is to keep as much of it as they can"

What state are you in? I dropped blue cross because it covered everything....except what I actually need. Fight it! The more voices fighting, the more progressive is possible.

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Quote from: arimoose on December 24, 2014, 04:37:34 PM
What state are you in? I dropped blue cross because it covered everything....except what I actually need. Fight it! The more voices fighting, the more progressive is possible.

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The companies I've worked for only offered two insurance options Yes or No. Most were sub 300 employees, yet one was likely 300,000 total worldwide. 

I started the ball rolling today. Unfortunately, the hospital's relevant personnel went home early today (there must be a holiday or something), but the Blue Shield guy will follow up next week. I'm being told that there was no diagnosis code, but my paperwork implies that the procedure DOES have a diagnosis code, but it is at odds with my recorded sex. At least, that's how I'm interpreting all of this, but I'm no insurance professional, so I could be way off base.

This is the same sort of line I was given on that office visit--a coding issue. Unfortunately, I couldn't follow up on that one today because I needed to talk to the same clinic people who went home early--I wanted to talk to them BEFORE talking to Blue Shield so that BS couldn't give me any BS.

Next week...

BTW, I am in trans-friendly California. Haha, what a joke.

I wish cis people could experience life from my perspective. The self-hatred, the self-harm, the dysphoria over my body, the meltdowns because bureaucracies single me out and make me feel like a freak. I keep telling myself that old saw--is it Eleanor Roosevelt?--that people can't make me feel inferior without my consent, but the problem isn't just that I feel inferior; it's that I'm being given inferior service because I'm seen as other. Quite a different story, in my book. But it doesn't help that I have half a lifetime, forty-odd years, of hating on myself. The others don't have to do much to awaken that sleeping dragon.

I have anthem and they have dicked me over totally, too. I can't get any care now. They wouldn't even pay for my routine physical.  Ironically, the only thing they really do pay for is my psycho therapy, which I am needing a LOTTTTTT more of as my health languishes.

I had an endo appointment way back in March. In October they suddenly decided it wasn't covered and  the one visit ended up costing me over $700.

Anthem BCBS SUCKSSSSSS!:(

Sorry for typos and weird random words,  I have no internet or a computer, just a phone

Quote from: ElizMarie on December 24, 2014, 10:35:01 AM
Go to your employer's benefits office (usually part of HR) and give them all of the particulars.  I've had this same kind of thing happen, and usually, they have inside (within BS) help to straighten things out.  If they don't help you, they can at least give you the name and phone number of the patient advocacy group within BS.  (Every insurance company has to have one of these now, at least from what I've read.) 

If none of that works, THEN get in touch with your state's insurance commissioner.  Usually, they have staff that works with insurance companies to help settle disputes like this.

This seems like good advice to me.

You should do some checking.
Massachusetts, for all it's communistwealth shortcomings and authoritarian BS, has "Transgendered" as a protected class.
That would make this legally actionable, immediately.

Your state may vary, of course.

However, if you have "Reason X" as the stated reason for any action / visit / etc., and BCBS is jerking you around - it could amount to fraud (which, in our insane society, may be legal; there's a reason we're heading to another war at home). Talk to a lawyer, bring the contract that BCBS supplied when you signed up, and the lawyer might well be happy to do it as a contingency.
Damages are minimal, though it can still be many orders higher than your loss/inconvenience; but Punitive Damages?  EVERYONE hates insurance companies these days.

Wait until the socialized medicine (and the fiat law behind it all) REALLY kicks in!
People who couldn't afford healthcare before? Soon will be paying penalties they cannot afford, for not having the insurance they can't afford, now that it's "free."

I'll STFU before I turn this into a rant.  :-)

Quote from: Arch on December 24, 2014, 05:58:26 PM
I wish cis people could experience life from my perspective. The self-hatred, the self-harm, the dysphoria over my body, the meltdowns because bureaucracies single me out and make me feel like a freak. I keep telling myself that old saw--is it Eleanor Roosevelt?--that people can't make me feel inferior without my consent, but the problem isn't just that I feel inferior; it's that I'm being given inferior service because I'm seen as other. Quite a different story, in my book. But it doesn't help that I have half a lifetime, forty-odd years, of hating on myself. The others don't have to do much to awaken that sleeping dragon.

Keep dreaming!
We live in a world where the lunatics are running the asylum!
Motorcycle helmets, for example.
Abortion, for another.
Capital Punishment, also.

Not to argue points, just to MAKE a point:
- Conservatives generally oppose Abortion, citing it as murder; but then support capital punishment anyway.
          - Liberals tend to reverse that: no capital punishment, but abortion on demand.
Motorcycle helmets and similar riding accessories are less charged, so I'll use them more.
"Ape-hanger" handlebars are generally banned.
Helmets are generally mandated.
The laws are written by people who don't ride motorcycles!

Handlebars don't matter - it might LOOK stupid, but it really has no bearing on "safety."
Helmets are a ->-bleeped-<-ING WASTE on the highway, a lot of the time. It's like scrambling an egg inside the shell - sure, the HEAD is still there, but there's nothing left of the brain.  (Like a boxer who's spent 20 years in the ring...)
But it's "unsafe" to ride without a helmet....

Anyone looked at the "safety" gear the kids must wear these days? For riding a scooter or rollerskates, kneepads, helmet, elbow pads, and though not mandated yet, there are guards for the hands, too. Oh, and the scooters? they're cmoing with FOUR wheels now, to make sure the kid can't fall over so easily.

How lovely the same attitude is in medicine! Changing our hormones to match our minds is illegal and immoral to these busy-bodies, and since we MUST - AT GUNPOINT - buy their "services" (Whether talking DMV, Cops, Mayor, Librarian, Dog catcher, and now insurance salesman, ENDOCRINOLOGIST...)  - yet so few of them have a <cenosred> clue what we're going through!

(Of note, it's also frequently true that the law-makers arrange for their CHOSEN "EXPERTS" to be the only ones able to talk before they decide on laws. EX: Gun control laws, discussed on a Tuesday, in a town with no rail access - Lexington, not Boston - at 2 PM, I think it was.  Many of us can choose to work and eat, or go and remind people it's a right enshrined in the Constitution they swore to uphold - but we can't do both. OTOH, the paid shills WILL be there, and since the difference between citizen and "tax cattle" is always the Second Amendment...? Guess which side they're ALWAYS shilling for.

Same with the motorcycle laws: No riders on the comittee, but "experts" showing that there's an increased SURVIVAL rate...  Even at 55 MPH!
Yes, you "survive," for another month to 10 years...  In a body cast, shattered, brain-dead, missing limbs and organs. Some <censored> life that is. At least you're not conscious to know you're eating and eliminating through tubes...

Lastly, it's "Freedom of Choice!" when it's "just a collection of cells" for a woman.
But we want to alter the "collections of cells" that make up, unequivocally, OUR BODY, and you'd think we were comitting an affront to GOD HIMSELF! And I'm referrign to the PROGRESSIVE LEFTIST FILTH, forget the looney religious right! As a (genetic) man, and not even a professional athlete where you could argue "fairness" (more BS), I can't get steroids - even if I have bad testicles! Without massive hassle of prescriptions, and then they want to use the weakest sauce they can, even if I'll pay for things out of pocket. As a genetic male who wants to resemble a woman in every possible detail, I need to get their PERMISSION to ge estrogen and Progesterone, (though those at least aren't Schedule 3 drugs like testosterone is - like crack cocaine, essentially). Then RLT, and therapist letters, and GOD help you if you get arrested! Without the surgery, you can be sent to a male correctional facility. WTF?

And as a "final" rant piece: Ever notice how those same prgressives are about as tolerant of {fill in the blank} as the KKK is of blacks? Mr(s). Limosine Liberal tells everyone ELSE how to be accepting, loving, kind, genteel, and inclusive to the blacks/Hispanics/Chinese/Japanese/Koreans/Indians/Muslims/Pakistanis/Women/Transgendered/Jews/Communists/Socialists/Bisexuals/Crossdressers/{Whatever}, then they go home to their mostly-white, gated community, in their chauferred limosine, to their ancestral mansion... (Yes, I'm exagerrating for dramatic effect; Warren, Bush, Clinton, Obama, Reagan, etc; think ANY of them knew a "common man" ANYWHERE?)  While the REST of us are left dealing with reality, on the stipend of our income left to us from their "generous" gluttonous claws, clawing out our wallets and life's blood.
See second amendment; tyranny; C.S. Lewis quote on same.
If stealing 100% of our money is slavery or theft - at what percentage is it not? Especially since if I walked up to you on April 15th and put a gun in your ribs, demanding 30-50% of your income, that's "theft", but when the only LEGALIZED gang with guns does the same thing, it's "taxes"?

If a woman has the right to terminate a cluster of cells which would otherwise grow into a human being - why can't I grow two clusters of cells on my chest, NEITHER of which can become a human being, ever?

It's not Insurance.
Not BC/BS.
Not the Liberals.
Not the NeoCons.

It's the busybody control freaks who wish to OWN us.

And we must fight them, as they understand no other language.

I'll go back to lurking now...

And please recognize I made the arguments not to get us into politics per se, but to reckognize the foolishness around us, so there's no question of what we're facing, and the solution. More laws don't help, we have over 10,000 at the Federal level ALONE. FEWER, CLEARER laws would work, and LESS taxation. It's not my OBLIGATION because I have a job to support those who do not (as it is quickly abused from helping those on tough times - charity - to enforced charity that cares for freeloaders). Just like every system, it can be gamed.

But if we have to keep our noses out of everyone else's business...?  Maybe it's only John/Susie's business if (s)he wants a nice rack. Maybe it's Jimmy's business if he wants a Hummer instead of a Leaf. Who am I to decide FOR THEM what they need? Or must buy? Or cannot have?

Lunatics running the asylum - and we, the doctors and staff, HAVE ENABLED IT. 

Let's start correcting it....

Hey Arch, you are going to prevail on this.  California requires transgender inclusive care.  You are smart to consider the State Insurance Commission, an appeal process within BS and an appeal to a supportive State legislator.  Turn that anger into determined and persevering dedication to your cause, YOU!  Steady persistence can get you past the gatekeepers to the manager's boss.  You are seeking medically necessary care and your care providers need to be your ally not an obstacle.  What you need is completely reasonable.

Thank you for sticking up for yourself and, in doing so, for the rest of us.

I've had issues with BCBS in the past, because I was covered under my Dad's teacher policy while I went to UCI for undergrad.  They made my life complicated for routine medical care, I hadn't even started trans-related stuff at that time.  I'd highly recommend you find a health clinic that specializes in being low cost and has trans services.  I've been pretty lucky with Health.net, they haven't shorted many payments, and my prescriptions are always covered.

One wrench in the system for the trans-men, there's a class action lawsuit for testosterone treatments causing bad stuff to people that aren't trans and don't need it for transitioning.  It also can cause adverse effects to trans people, but we have to sign up for transitioning knowing we might someday get blood clots, thrombosis, heart attacks or stroke.  It's why some clinics won't provide trans services unless the patient quits smoking, since smoking increases those chances.  A lot of specialty surgeons won't operate on smokers either for similar reasons. It's possible that some insurance companies might be trying to prevent being sued for paying for hormone treatment, without realizing how this effects the trans-community.

I know it sucks, but being trans can be very expensive.  Make sure you stay focused about keeping the job you have, because trans services are rarely free.  There will be ignorant people and bigots that you will come across, but I'm pretty sure the people at BCBS + Anthem are merely operating under a company directive and dicking over everyone universally.  You just happen to have a greater need for a helpful insurance company, it may not even be because you're trans.  It could just be beaurocracy.

Good news for CA at least, you are able to get your DMV license's gender marker changed as long as you have a physician or psychiatrist/psychologist that's able to vouch that you have received "appropriate treatment," toward your transition.  With a physician, you can permanently change your license, with a psychologist/psychiatrist you can change the license for 5 years, then it expires and reverts back unless you provide a secondary thing I think.  The new changes went into effect this year, removing the requirement for SRS.  Name changes were also modified, and don't require publishing in the newspaper if you only change your name at the time.


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