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Hi, I'm Noah Lewis, Executive Director of Transcend Legal. Welcome to our second video
in this series about how to get trans-related health care covered under insurance. Thank
you for all of the comments and questions, we'll be answering some of them in this video
and the next one. If you haven't had a chance to watch the first video, definitely go back
and check it out. But to recap, I discussed how it's time to stop paying out of pocket
for trans-related health care. It's time to stop going without the health care that you
need. If you're paying insurance premiums, you deserve to be able to access health care
under your plan. There are legal protections in place, and trans people have the opportunity
to collectively stand up and get the health care that we deserve. In law school, my student
health insurance plan excluded trans-related health care. Thinking about challenging that
exclusion was exhausting. But one day I decided I wasn't going to take it anymore, and I
chose to stand up for myself. It was a lot of work and it was emotionally draining, but
eventually they changed the policy. That fight was hard in part because I didn't have anyone
to help me. That's why I founded Transcend Legal. I know how life-changing hormones and
surgery were for me, so I work full-time helping other trans people to get the health care
that you need to transform your life. Thankfully, I don't have to work alone anymore. One
of my colleagues at Transcend Legal is Charlie Arrowood, and I want to introduce you to him
now. Hi, my name is Charlie Arrowood, and I'm an attorney with Transcend Legal. I've
always had weird feelings about my gender, but I didn't think of myself as trans until
a few years ago. I socially transitioned about 15 years ago—well before identifying as
trans—but I never bothered doing anything to medically transition because I was overwhelmed
by the thought of finding the right providers and getting coverage. Fortunately, last year
I met Noah and started working with Transcend Legal. I was able to learn the ins and outs
of trans insurance coverage. It took lots of phone calls and paperwork and lots of help
from my wife and her employer, but I was ultimately able to get full coverage for both hormones
and surgery, despite not identifying as a binary trans man. Having surgery was hugely
meaningful to me. I can stand up straight. My clothes fit. And I don't panic about getting
in the shower anymore. It was literally and figuratively a huge weight off my chest, and
it never would have happened if it weren't covered by insurance. But you are not alone
if you are confused by how to get surgery covered. I'm an attorney and until I started
handling it for other people, I didn't understand even the basics of insurance, let alone any
of this trans stuff. Our goal here is to explain the basics to you so you know your options,
but you may need individualized input or assistance from someone who specializes in trans insurance
issues if you're still having a hard time getting coverage. In this video we're going
to answer the question of how to go about applying for insurance coverage. We're not
going to be giving you any legal advice about what you personally should do, but we will
be giving you general information about the process. We're going to start by telling
you about one more document you need to get in order to understand what your plan will
cover and what you need to do to get that coverage. In the first video, I explained
how to find out what your particular insurance plan covers. I explained how to get a copy
of your plan booklet and what to look for once you get it. Hopefully by now you've
been able to get a copy of your plan booklet, or at least have requested it. But there is
a second document you need that I briefly mentioned in the first video. This is your
insurance company's medical policy on treatments for gender dysphoria. It may be called things
such as a Medical Coverage Policy, a Clinical Policy Bulletin, or Clinical Criteria. We
have compiled a list of over sixty such policies under the resources section of our website
at transcendlegal.org. So that should be your first stop for trying to locate the policy.
If it's not there, you can call the number on the back of your insurance card and ask
them to send it to you, though not all companies have a specific policy on transgender care.
What a medical policy is, is the insurance company's guidelines for what kinds of evidence
it wants to see before it will pay a claim. Most of these policies have onerous requirements
that are not in line with the standards of care of the World Professional Association
for Transgender Health or WPATH. The policy provides you a roadmap of the information
that you need to give to the insurance company. This is generally one or two letters from
a therapist, and these policies outline what should be in those letters. There may also
be other requirements such as having persistent gender dysphoria, being on hormones for a
year or being at least 18 years old to have surgery. If you do not meet the requirements
in the policy, that doesn't mean that you have no hope of getting coverage – you'll
just have to challenge the denial if you are denied based on that policy. So when you are
asking your mental health provider for a letter, give them a copy of the medical policy and
tell them to make sure to explain how you meet all of the insurance company's criteria.
If you don't meet the criteria, have the therapist explain why the criteria shouldn't
apply to you. While many insurance companies recognize, for example, that being on testosterone
is not required before undergoing top surgery, some still may have this listed as a requirement.
In addition to your therapist, you can also get letters from your hormone doctor and your
surgeon in support of the surgery. Ask your provider to start the letter by listing their
own credentials including their education, experience working with trans people, and
any relevant training, publications, or professional memberships. Some providers write minimal
letters because they don't want to pathologize trans people. But that isn't helpful when
it comes to proving that the treatment you need is medically necessary. While there's
nothing wrong with being trans, trans people who are seeking access to medical treatment
know that there is definitely something about their body that needs to be changed in order
to alleviate their gender dysphoria. We're not yet at the point where trans coverage
is automatic, particularly for things like facial surgery and breast augmentation. So
the therapist letter shouldn't just say that the person is ready for surgery and understands
the risks of the procedure. They need to describe how the person has gender dysphoria and list
the specific challenges the person faces because of it—such as being depressed, being afraid
to leave the house, or needing to wear a binder. The letter should explain that they need to
change their sex characteristics in order to alleviate their gender dysphoria. People
aren't having surgery because it's a lifestyle choice. This is medical treatment for a particular
diagnosis, and provider letters need to make that clear. Some people have asked if it's
possible to forgo getting a therapist letter. Most insurance company medical policies don't
require therapist letters for hormones, except for puberty suppression. If you go to a provider
who uses an informed consent model, then it's possible to get hormones without a therapist
letter. But for surgery, one therapist letter for top surgery and two letters for bottom
surgery is what the WPATH Standards of Care currently recommend, and what most surgeons
follow. Because therapist letters are still the standard of care, there is no strong basis
to challenge an insurance company requirement for these letters. So once you know the insurance
company's criteria and are working on getting your therapist letter, you'll want to actually
apply for coverage and see what the insurance company says.
This process is called getting preauthorization or prior authorization. In Medicare Advantage
plans, it's called an "organization determination." You can do this regardless of whether or not
your plan excludes trans-related health care. And if you've already had surgery and paid
out of pocket, then you would go ahead and submit a claim for reimbursement. Sometimes
the insurance company may give you a hard time or deny full benefits if you did not
apply for preauthorization, so it's important to do that even if you plan to pay out of
pocket. Now you could just call the insurance company
and ask if they cover it, but that's not really going to give you a definitive answer. The
people who answer the phones are not given the best training, so they may just tell you
it's excluded, or worse, tell you it's covered when it's really not. But even if
they tell you it's covered in general, that doesn't mean it will be covered for you
specifically. So that's why it's important to get a determination about your particular
situation. Applying for preauthorization results in a
formal decision can be appealed if it's denied. Ideally, you want to have your surgeon
apply for preauthorization. So you want to find a surgeon and have a consultation. When
choosing a surgeon, find out if the surgeon accepts insurance or not. If they do accept
insurance, determine if they're in network or out of network for your plan. To do that,
go to your insurance company's website, and search in their "find a doctor" section.
Also search for the facility where you'll have your surgery to make sure that's also
in network. If the provider is out of network, find out
if they will give you the proper paperwork to make it easier for you to be reimbursed
by your insurance company. Some of the most popular surgeons won't help with insurance
paperwork at all, which makes the process more of a hassle than it should be. Most surgeons
now have a person who handles working with insurance companies. That definitely makes
things easier on you, so take that into consideration when choosing a surgeon. If you're not able
to pay out of pocket and be reimbursed, there's something called a Single Case Agreement that
a nonparticipating provider can enter into with the insurance company. So, if you know
the doctor or surgeon you want to go to and you've already had a consultation, have that
provider submit a preauthorization request. If your surgeon does not accept insurance
or is unwilling to submit the preauthorization request, you can ask your primary care provider
to do it, or you can do it yourself. And what happens if you do get coverage? How much will
you have to pay out of pocket? This is where you'll want to look at the Summary of Benefits
and Coverage chart for your plan. First, find out what the deductible will be. The deductible
is the amount you must pay out of pocket before the insurance plan will even start paying
benefits. There may be separate deductibles for in-network and out-of-network care. So
even if you've already met your deductible for in-network care, but you're choosing an
out-of-network surgeon, you're going to have to pay the full out-of-network deductible
before coverage kicks in. The good news about a deductible is that once it's met, it's met
for all of the care you receive later on in that same plan year. Note that the plan year
might not run from January to December. The coverage period will be listed at the top
of the Summary of Benefits so you'll know on what date the deductible you've already
paid resets to zero. So, let's walk through an example. If your surgery costs ten thousand
dollars and you have a $3,000 deductible, you'd be paying $3,000 out of pocket if you
have not already contributed anything towards your deductible. But then what happens? Is
the remaining $7,000 fully covered? Probably not. This is due to copays or co-insurance.
A copay is a fixed amount you must pay for certain services. So, your plan may have a
$75 copay for outpatient surgery. Or instead of a copay, you may see that it says "co-insurance"
such as 20% co-insurance for in-network benefits and 40% co-insurance for out-of-network services.
"Co-insurance" is a clever insurance industry term meaning that you yourself are partly
responsible for paying for the service. It means you pay 20% or 40% of the cost. While
it's rare, you should ask your benefits administrator or HR if your employer has any programs to
help cover co-pays and co-insurance costs. My insurance covered my surgery, but I still
would've had to pay that portion. Because my wife's employer was enrolled in a special
plan that paid the co-insurance, we ended up paying nothing. So, continuing on from
our earlier example, of the remaining $7,000 after the deductible was paid, you would owe
20% or $1,400 if the surgeon and the facility were in-network and $2,800 if they were out-of-network.
Note that you can go to an out-of-network surgeon who performs the surgery at an in-network
facility or vice versa. So, this is all starting to add up. With the deductible and coinsurance
combined, you're looking at $4,400 for in-network or $5,800 for out of network. This is where
the out-of-pocket limit comes in. The out-of-pocket limit is the maximum you will pay out of pocket
in a given plan year. So, in this example, the out-of-pocket limit is $3,500 for in-network
and $7,000 for out of network. So that $4,400 figure? The insurance company can't collect
that from you. The most you would pay is $3,500 if your provider and the facility were both
in-network. But if your provider and the facility were out of network, you'd still be stuck
paying the $5,800. So, you can see how important it is to find a surgeon who is in network.
It can mean thousands of dollars difference in the cost of your surgery. This is why if
you can't find a qualified in-network surgeon you'll want to ask for your provider to be
considered in-network for billing. Your in-network primary care provider can put in a request
to the insurance company, and ideally you'll want to have the letter from the surgeon as
well explaining the specialized nature of the care. The same process would apply if
you have no out of network coverage at all and need to go to an out of network surgeon.
If you plan pay-out-of-pocket up front and seek to be reimbursed, there is another thing
to be aware of. The insurance company doesn't have to reimburse you the full amount. In
addition to the usual deductible and co-insurance, if your surgeon has charged an unusually high
rate, the insurance company doesn't have to pay the full amount. They only have to pay
an amount that is usual, customary and reasonable. Those numbers aren't well-defined for trans
care, but you can try to find out from your insurance company beforehand what their allowed
amount will be, and you might be able to challenge it if their amount is unreasonable. There's
one last thing we want to flag. Sometimes when employers with self-funded plans remove
trans exclusions and add explicit coverage, they're afraid that all of their employees
are suddenly going want to transition. So, they impose a special lifetime cap on trans
health care, often $75,000 or less. However, given that no other type of care has a lifetime
cap, such limitations are unlawful discrimination and can be challenged. So, to recap, in this
video we've explained how to get your insurance company's medical policy to understand the
information you need to provide in order for your care to be covered. We explained what
makes a good therapist letter, how to apply for preauthorization, and how to calculate
your out-of-pocket costs. But what happens if the insurance company denies your preauthorization
request or post-service claim? This is not the end! In fact, now you can appeal the decision.
Our next video will cover your appeal rights and what to do if you are denied. I hate to
see any trans person with insurance going without surgery or trying to raise money so
that they can pay out of pocket. Since trans people have been getting denied coverage for
so long, I know that people are skeptical about getting insurance coverage and think
it won't work for them. If that's the case for you, then stay tuned for our next
video. We'll be sharing some stories of people who have successfully gotten coverage
and what that process looks like. Hopefully you will see that this is possible for you
as well. Please scroll down and leave a comment so that we can know if these videos are useful
or not. And please share this video with your friends. Together we can make sure that all
trans people get the health care that they need—with insurance. Thanks for taking part.
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