Transition and insurance

The first rule of insurance: there are no definite rules.

Do not assume your policy will work the same as another person's, even if it's from the same carrier. Policies are tailored to companies and individuals. You must look at your own policy for information about coverage.

This is a very general overview, since there are few hard and fast rules when it comes to insurance coverage. For more on financial issues, please see my section on financing transition.

Much of the information below was provided by insurance specialist Erika Ervin:

Erika Ervin
(323) 394-3349
erika_e_soaring@yahoo.com

Erika can answer many insurance questions, especially in California.

LINK: The Health Care Options Matrix™

Print or download your state’s free quick-reference guide to public and private health care options

In 2006, Erika compiled a document on Health Insurance Equality that is a must-read, though it was superseded by the Matric info above:

For the Employee in Transition: Health Insurance Options (PDF)

General advice

Do not plan financially on getting insurance coverage for trans health services. You might get it, but many claims have been denied. Don't just give up, though. Be sure to review your policy and see what your options are.

Erika Ervin notes:

Even if health insurance doesn’t cover SRS or HRT doesn’t mean to steer away from health insurance as a financial protection and planning tool. Your thinking should be whole body and what we put it through to complete the process. Health insurance that may not cover surgery is better than no insurance at all in the absence of a plan design that excludes trans health services. It will happen and my strategy is going to take a couple years.

Read your policy very carefully

Don't just rely on the synopsis provided in an employee manual. Read the copy of the policy itself, and copies of anything you sign.

The most important thing to do is read the exclusions. This is where you are most likely to find specific exclusions for "transsexual surgery and related services."

"Pre-existing condition"

Some women have been denied coverage because the insurance company determines their transsexualism was a pre-existing condition. In other words, they'll say you knew you had this condition when you signed on, so they are not obligated to cover it. You can get busted through proof you had been seeking treatments for transsexuality prior to coverage. If they want, they could even get nasty and say you committed fraud by not reporting the condition at the onset.

Unemployed

You are going to be in big financial trouble in transition without a job. While some companies cover part-time employees on insurance, you'd be wise to get a full-time job, any full-time job, if you expect any insurance coverage.

Self-employed

You might be wise to speak with a lawyer about options if you own your own business. Obviously, you can tailor your policy as you see fit, but the costs to cover TS stuff may be prohibitive, and they might get you on the "pre-existing condition" clause. In other words, they'll say you knew you had this condition when you signed on, so they are not obligated to cover it.

In a union

This can be good or bad. Oftentimes, unions have gone to bat for TSs, although the exact opposite has been true. I'm pretty unfamiliar with blue-collar work situations or unions in general. I suggest speaking with your union rep about this.

At a small company

This can be good or bad, too. If the boss likes you and wants to keep you around, you might be able to convince them to get or change their policy to cover you. Sometimes a small company cannot afford the increased premium they'd have to pay to cover insurance, though.

At a large company

Again, this can be good or bad. Large companies often offer a choice of insurance, such as an HMO and a PPO. Check all policies before signing on. One might cover out-of-network providers better than another. Many gender therapists and doctors who provide TS services are not part of insurance networks. You may also have a choice of Primary Care Physicians. Mine was totally cool about covering HRT. All I had to do was ask, even though it's a specific exclusion.

Coverage for specific treatments

Hormones

Many women get HRT covered through insurance as a "hormonal imbalance." This usually slips under the insurance radar even on policies that specifically exclude transsexual surgery and related services. Prescriptions go through rather easily in most cases, but some have reported difficulties with injections. due to the expense and office visits.

Postoperatively, you should have no problems getting hormones covered.

Therapy

This one is quite easy to get through by listing it as "depression."

Facial plastic surgery

Some have been able to get face work tacked on as part of other corrective procedures. One woman writes she had her nose fixed during a correction to her jaw following a car accident. Another got her chin feminized as part of oral surgery to correct her overbite.

SRS

This is usually the hardest to get covered. Many policies specifically exclude SRS.

A little background: SRS was routinely covered in the US until a couple of medical articles came out in the late 1970's showing high suicide rates among post-operative women. This came at the same time a couple of prominent gender clinics were closed, notably Johns Hopkins.

The insurance companies pounced on these events as a chance to decry the procedure as elective, cosmetic, or experimental. It's been an uphill battle since.

While many women have not been able to get insurance coverage, some have. Usually, there are a lot of hoops through which to jump. In many cases you have to pay up front out of pocket yourself and get reimbursed, so you may need to save as if you will not be getting covered.

Some insurance companies require you to meet in front of a board of company-appointed doctors for evaluation.

The news isn't all bad, though. Taylor writes:

Minnesota has some very enlightened laws concerning the insurance industry and patients at large. I know personally of four cases here in Minneapolis, where Medica, A Division of Allina Health Systems, has paid for SRS in its entirety.

The first time they did this, another attorney here confronted them on the basis of discriminating against our patient population. After a successful out of court settlement, Medica is covering all subsequent operations. I believe other health carriers here will follow their lead for very good reason. It's cheaper to pay 15 to 22 thousand dollars for a few operations, than defend against a class action suit which might result in payment for the surgery anyway, and compensatory damages including the legal fees of the patients.

I have found a very common practice in several states, where insurance companies will pay for psychotherapy, hormones, and other health related treatments. It depends on the language of the insurance policy itself and their willingness to abide by it. Often times a 50 to 75 dollar letter from an attorney to an insurance company can get the money flowing to the patient.

Setting up a medical expense account

This can be a good option for planning and saving for medical expenses tax-free. However, you usually have to use all the money within a given time frame (usually within that calendar year). The cool thing is you can use this for any medical expenses, since it's not related to insurance. Check with your benefits administrator.

Elizabeth writes:

Some companies (mine included) have a fund that you can contribute to each year that you can then draw out tax-free to pay for unreimbursed medical expenses. Whatever you agree to contribute, and there is usually a cap, is available on Jan 2, even though you would continue to pay via payroll deductions throughout the year. Because this fund is free of all deductions, it can amount to a savings of 40 cents on the dollar or more. My HMO, like most, specifically excludes all expenses related to SRS (though I paid for mine long before I came to work here), the unreimbursed fund is for just such expenses.

Health Savings Accounts and Individual Retirement Accounts

Erica writes with some information:

This is an important development if you wish to put it up on your site. I've always been an advocate of HSA's (Health Savings Accounts) as a planning tool for funding surgeries for TS folk. Now your can roll-over your IRA into an HSA to avoid taxation.

In early 2007, California proposed enacting major changes that may include universal health coverage for all state residents:

Erica adds:

After reviewing individual and family plans to see if anything is covering GID I have come to the conclusion that the replies will be Auto Decline across the board.

If so take your “Letter of Declination” and apply for the California Major Risk Medical Insurance Program, which will cover HRT, Lab Work and Depending on the Plan Mental Health Services which are considered “Medically Necessary”.  It will not cover Primary Gender (“Genital”) Surgery; and only a large group plan or TPA (Self-Funded) customized plan will do that if the employer elects it.
 
http://www.mrmib.ca.gov/MRMIB/MRMIPBRO.pdf

It’s better than having no coverage for those of us who are self-employed or don’t have an employer sponsored plan.

I got the following from Erica in February 2007:

I’m happy to report that I received the reply from the underwriter (see below) that although there is a Pre-existing Condition Exclusion for six months.  The limited medical plan will cover GID under the Mental Health benefits section.  
 
I started work on this program last year, and depended heavily on the Dr. Horton’s research and the SF actuary experience summary in selling it to the carrier.  Wes Huffman of America Protect spearheaded it with the underwriters, making this the free market’s response to a National Health Insurance initiative, it just happens to cover GID.   
 
It is a Limited Medical Plan and I’m curious how well it does in the market place.  Take a look at it with a discerning eye for utilization.  
 
General Utilization Notes.  

The program is guaranteed issue in all 50 States as a group plan through the National Congress of Employers www.thence.org <http://www.thence.org>
 
If you’re pre-diagnosed with GID there will be a six month waiting period before the plan benefit can kick in.
 
There isn’t an auto-delineation for GID important.  
 
There is an association benefit (see link www.thence.org <http://www.thence.org/>  )
 
The plan will cover hormones at a discount similar to that of a pre-negotiated PPO discounted rate.
 
The plan will cover 5 doctor’s visits and one wellness visit a year at the scheduled reimbursement rate(see plan choices) under a first dollar payout—that means you can see a gender specialist or endocrinologist.  You’ll pay less if you see a provider doctor, but you don’t have to under this plan.  
 
The plan will cover 3 lab tests per year at the scheduled reimbursement rate (see plan choices).
 
Psychotherapy is a covered benefit; see Policy Year deductible, insured percentage and Policy Year Maximum.
 
It will cover mastectomy and post mastectomy reconstruction.
 
The plan does not cover genital surgery.
 
General Notes:
 
At this time I don’t see trends will allow for genital surgery, breast augmentation or FFS to be covered under individual policies at this time, and only trough group major medical will that be possible.  
 
I feel it’s the best we have so far.  

1. AmericaProtect (PDF)
2. Defined Benefit (PDF)

I just wanted to give you an update and a link to the Matrix; Health Care Options in All 50 States.
 
http://www.coverageforall.org/index.htm

The Health Care Options Matrix™

http://www.coverageforall.org/our_services.htm#options

Print or download your state’s free quick-reference guide to public and private health care options

Thanks to Erika for passing this information on!

My recommendation:

Again, do not plan financially on getting insurance coverage for trans health services. Make every effort to get coverage, but do not base all your plans on getting covered. You could be setting yourself up for an enormous disappointment and could be putting yourself into a major financial bind at the moment of truth. If you do get coverage, you'll be ahead of the game instead of scrambling to make ends meet.

For more on financial issues, please see my section on financing transition.

You might also find it interesting to read this analysis of the San Francisco City and County Transgender Health Benefit (PDF). It demonstrates that massive numbers of claims from trans people do not occur once coverage is initiated.