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Insurance Coverage for Gender Affirmation Surgery

Understanding Insurance Coverage Options

How can I get insurance coverage for gender affirming surgery or gender reassignment surgery? After preparing for and even scheduling your surgical consultation, you may be wondering how to get insurance to cover gender surgery. Insurance plans can be complex, and securing coverage for your medically necessary gender-affirming surgery even more so. At the Gender Confirmation Center (GCC), our insurance concierge team will work to secure you the most affordable care. In this article, we will cover the elements and areas of insurance coverage that matter when seeking gender-affirming care.

Types of Insurance Plans:

There are a number of different plans offered by providers of insurance. These include public, employer-sponsored, or private insurance plans. Public insurance plans include Medicaid (federal and state insurance plans offered to those with limited income) and Medicare (insurance plans offered to those 65 or older and with disabilities). Private insurance plans tend to be employer-sponsored self-funded plans or offered by private insurance companies. This means the employer or private insurer develops the nature and scope of coverage and financial responsibility. These different insurers and their respective plans may or may not cover various types of gender affirmation surgery. It is important to understand how to read your policy to identify coverage to identify if your provider offers coverage of gender benefits or not.

Steps to Understanding Your Plan:

Your insurance policy will offer a comprehensive guide of medical services it covers, at cost or with deductibles, copayments, or out-of-pocket costs. It is important to understand that the cost of your surgery will be affected by all three of these elements determined by your provider. One provider may offer medically-necessary FFS with a deductible. Another provider such as a private insurer may not find FFS to be medically-necessary gender-affirming care and will thus reject your pre-authorization request, requiring you to pay out-of-pocket costs. We have a list of some of the providers we have been able to successfully secure coverage from here. If you have specific questions about your plan, you can reach out to us at advocate@genderconfirmation.com with the copy of the front and back of your insurance card.

Key Terminology:

Understanding the following insurance terminology can help you better navigate this process:

• Pre-authorization: This term refers to the services insurance providers determine are medically necessary and therefore are pre-approved or eligible for coverage.
• Exclusions: This term refers to provisions in insurance policies that exclude a certain medical procedure, act, or equipment from coverage. An example might be cosmetic surgery that is not a result of a medical injury.
• Medical Necessity: This term refers to your insurance provider’s determination that the procedures listed in your benefit plan are necessary to restore your health.

As you might already sense, these three terms are especially important for medically-necessary gender affirming care. Insurance providers offer successful recompensation to claims made that are authorized and medically necessary. Obtaining coverage for medical treatments, procedures, or equipment can be challenging, especially if they are excluded or not pre-authorized. That’s why GCC recommends going through the pre-authorization process first. A denied claim without prior authorization can lead to significant difficulties when trying to secure reimbursement.

If your pre-authorization request is denied, our insurance advocate is here to guide you through the appeals process every step of the way. We will go through these challenges next.

Challenges in Obtaining Insurance Coverage

Common Barriers:

The most common barriers to obtaining medical insurance coverage for gender affirming care include policy exclusions, denials of claims, lack of provider knowledge, and in-network vs. out-of-network providers.

• Policy Exclusions include provisions or policies that exclude gender-affirming care. These can either be explicit or implicit in your benefits plan. These exclusions may suggest that a tracheal-shave is not a medically-necessary surgery but a cosmetic one while HRT is medically necessary as it may restore health by relieving dysphoria.
• Denials of claims: Claim denials can occur when there is insufficient documentation, a lack of prior authorization or if your provider and insurer are not in a relationship.
• Lack of knowledge: Unfortunately, not every insurance provider and representative is familiar with gender-affirming procedures. You may find that this lack of knowledge can create a barrier or challenge when seeking to identify your gender-affirming care as a medically necessary procedure. For representatives, insurance covered gender-affirming care is still debated as a necessary medical service.
• In-network and out-of-network providers: Your healthcare provider, that is your surgeon or medical office, must retain a relationship with your insurer. If your provider is “out-of-network” this means that they do not retain a relationship with your insurer and are thus not legally obligated to claim your medical service through your insurer. That said, in many cases, through obtaining a referral letter from an in-network primary care provider, we can secure coverage for your procedure even if the GCC is out-of-network. In this case, processing the claim will take longer.

Steps to Appeal Denials:

The appeals process for individuals whose claims are denied can occur in two ways: internal appeals and external appeals. The first includes asking your insurance provider why they denied your claim, then replying with documentation and perhaps a letter of support from your Doctor asserting why your claim should be covered. Otherwise, the external review is completed by a third-party, with rights afforded by the state and federal governments. Depending on your provider, the appeals process can involve documentation and resubmission.

It is helpful to keep all documentation related to your insurance coverage. At the GCC, our insurance concierge team will work with you to ensure any claims and their appeals proceed smoothly. Our team will submit documentation and advocate for you on your behalf. We have a 90% success rate of securing coverage for interested patients.

Legal Protections and Advocacy

The following are legal protections and resources for legal advocacy available to you.

• Federal and State Legal Protections:
  • ACA (Affordable Care Act): The ACA prohibits discrimination based on gender identity. This means that insurance coverage made available to patients by the ACA is federally required to offer medically-necessary gender affirming care. Under California state law, insurance companies are generally prohibited from discriminating based on gender identity, which includes gender reassignment surgery. The California Department of Insurance requires health plans to cover medically necessary gender-affirming procedures, including surgery, when deemed appropriate by a healthcare provider. However, specific coverage can vary by plan, so it’s important to review your policy and consult with your insurance provider to understand any exclusions or requirements that may apply. If you encounter issues, you might consider seeking assistance from an advocacy group or legal resources specializing in LGBTQ+ rights.
  • State Laws: At the state level, specific laws require insurers to cover gender affirming surgery. In California the protection against discrimination of trans youth and their families (SB 107). California has been described as a sanctuary state in this regard. Oregon has no laws that prohibit individuals from accessing gender-affirming care, and lawmakers are currently working on a bill that would offer protections for out-of-state patients seeking and healthcare professionals giving gender-affirming care. Lawmakers are also working to pass laws expanding the definition of medically-necessary gender-affirming surgery.
  • Employer-Sponsored Health Plans: Certain employer-sponsored health care plans may differ in their definition of medically-necessary gender-affirming surgery, as well as the kinds of exclusions and pre-authorizations they allow for surgeries closely related to them (e.g., rhinoplasty or liposuction). ERISA (Employee Retirement Income Security Act) plans, for example, give employers broad discretion in the design of coverage available to employees. Therefore, they may exclude gender-affirming procedures as medically necessary.
• Advocacy and Legal Resources:
  • There are also organizations that provide support and/or legal assistance like the Trans Family Support Services, the ACLU and Lambda Legal. These organizations may be helpful when facing denials. Please know that certain providers, like the GCC, have our own insurance advocacy services that we provide free-of-cost to patients.
• Navigating the Insurance Process:
  • When working with an insurance provider or case manager, make sure to keep all documents available to you and keep track of the language used to describe any reasons for denial.

Factors Affecting Insurance Coverage

Insurance Provider Policies:

If your insurance provider does offer transgender healthcare coverage, it can also be helpful to note how policies may vary across providers. Special considerations for transgender exclusions in certain plans, such as categorical exclusions, include seeing if a different provider can fill in the gap within a specific plan. This is the case for those who may be under 26 and under a parent or guardian’s insurance while also employed by an employer who maintains an ERISA.

The Changing Healthcare Landscape:

Policies regarding transgender health care coverage are evolving at both the federal state levels. At the federal level, prohibition of transgender care may be unlawful as sex discrimination, and federal law may be helpful in filling in the gaps insurance providers may neglect. At the state level, protections for healthcare providers and patients providing and seeking gender-affirming may improve access to coverage. Shifts in the political and legal landscape will have effects on future coverage by enforcing stronger protections or diversifying the means of access to care.

Medical Necessity and Documentation

The Importance of Medical Necessity:

Medical necessity is a legal doctrine that establishes activities that may be justified as appropriate according to clinical standards of care. This is separate from unnecessary healthcare, which is not legal from this point of view. In the context of gender affirming surgery, the justification of appropriate and reasonable activity according to clinical standards of care are essential to ensuring your gender-affirming care is medically necessary.

Insurance companies may evaluate this necessity in a prior-authorization review, where they determine if the procedure is medically necessary or not. This is most clearly proved by one or two support letters from a licensed mental health provider.

The Role of Healthcare Providers:

Letters from mental health professionals and healthcare providers can work to establish medical necessity, especially in the case of seeking coverage and appealing a claim denial.

Following the WPATH Standards or the World Professional Association for Transgender Health (WPATH) guidelines can strengthen a case for insurance coverage. Their Associations Medical Necessity Statement can be found here.

Documentation Checklist:

In order to document medical necessity, patients should thoroughly account the condition, symptoms, medical background, and prior treatments that are closely related to the treatment and demonstrate its necessity. This will be reviewed on a case-by-case basis, but here are some general points we’ve observed with insurance companies:

• 1. Patient is capable of making a fully informed decision and consenting to treatment.
• 2. Any significant medical or mental health concerns the patient has must be reasonably controlled.
• 3. The patient has completed at least 6 months of successful, continuous, full-time living in their desired gender.
• 4. The patient has undergone 12 months of continuous hormone therapy appropriate for their experienced gender. Top surgery is not required (except for Federal Employee Program insurance), but all other treatment (FFS and bottom surgery) hormone therapy is needed.
• 5. There is persistent and well-documented gender dysphoria.
• 6. For bottom surgery, the patient must understand how gender reassignment surgery (GRS) affects their ability to reproduce (currently required only by HealthNet).
• 7. The mental health provider (MHP) must have an established relationship with the patient, preferably for at least 12 months.
• 8. The member has access to post-surgery aftercare.
• 9. A support letter must be written within the last year.

Preparing for Surgery with Insurance

Another way of viewing these steps can be to think about your pre- and post-operative insurance goals.

• Pre-Authorization Process:
  • A pre-authorization review can be requested via your medical providers office for most plans. The patient can also submit this, but in the case of gender-affirming medical care it is helpful if an insurance concierge team can assist you.
  • You must check with your doctor’s office to see if the pre-approval process is underway. Typical delays include receipt, follow-up requests for additional or qualifying information. This can sometimes take a few days to several weeks.
• Working with Surgeons and Healthcare Providers:
  • Our providers here at the GCC are experienced with insurance processes for gender affirmation surgery. You will have no difficulties with our concierge team as they are highly experienced and successful with coverage.
  • It can be helpful to find surgeons who have a proven track record with insurance companies. You can find this information via patient reviews or insurance  provider websites.

Post-Surgery Insurance Considerations

• Coverage for Post-Surgical Care:
  • Aftercare services like follow-up appointments and revisions surgeries can also be included in your coverage. If your plan does not already include these services as medically necessary, ensure your medical team includes these services in your pre-authorization review.
• Long-Term Health Insurance Considerations:
  • Often gender-affirming medical care may require long-term healthcare activities. These may include hormone therapy continuation or routine medical care. Ensuring continued coverage for transition-related healthcare can involve a similar process of pre-authorization review. However, at the GCC, we encourage you to work with our insurance concierge team to meet these long-term needs.

Conclusion

With all of the steps and complications that can accompany insurance coverage involve deliberation, your decision to pursue medically necessary gender-affirming care is not up for debate. Taking the active steps to understand your insurance and advocate for your healthcare rights is also a part of your pursuit of gender-affirming care. With the right documentation, legal support, preparation, and insurance coverage your surgery can be secured.

For more information on which insurance plans cover gender-affirming surgery with the GCC, click here. If you have specific questions about your plan, you can reach out to advocate@genderconfirmation.com with the copy of the front and back of your insurance card.

And, just to boil this down to bite-size, here is a summary of most of this information as a flowchart, also downloadable as a PDF here: