ACA Insurance Coverage

Okay, I don’t know why this is all of a sudden in the news, back when the ACA bill was first passed there were article about the fact that we were covered. Back in 2012 I wrote about a news article that said,
The U.S. Department of Health and Human Services (HHS) has clarified that sex-based discrimination that is prohibited by the Patient Protection and Affordable Care Act (ACA) includes discrimination on the basis of gender identity and sex stereotypes.
There was a lot of talk about whether or not it covered surgery and I think most people thought if it wasn't covered it will be in the future. That it was only a matter of time, well that time has come…

With Coverage Through Obamacare, Transgender Woman Opts For Surgery
By Anna Gorman KHN Staff Writer
AUG 25, 2014

Payne learned in the fall that she might qualify for subsidies through the state’s new insurance marketplace, Covered California, because her income fell under the limit of $46,000 a year. She eagerly signed up in March for a Blue Shield plan for about $230 a month, and began making preparations for the surgery that would change her life.
[…]
Now, federal law prohibits health insurance companies from discriminating against transgender people, and it bars insurers from denying coverage based on pre-existing conditions. That makes it possible for more transgender people to purchase private plans. And in states that expanded their Medicaid programs, those with low incomes may get free coverage.

The federal anti-discrimination regulations have yet to be written, but California insurance regulators have said that companies must treat transgender patients the same as other patients. For example, if plans cover hormones for post-menopausal women, they must also cover them for transgender women. Medicare, the program for the elderly and disabled, lifted its ban on covering sex reassignment surgery earlier this year.

With no regulations yet to guide coverage many insurance are falling back on their standard answer… “No” they deny everything to see what sticks and what doesn't. So we may be covered for things like electrolysis and breast augmentation but it will be denied at first and we have to appeal the decisions until we get it covered.

Also the article points out another shortcoming of the coverage…

By the scheduled date, Blue Shield had authorized the operation but hadn’t determined exactly how much it would pay for an out-of-network provider.  Payne got a cashier’s check for nearly all her savings, $27,000, to pay the doctor, hoping her insurance plan would reimburse most of it. She worried about all the other expenses too, including the hospital stay, lab work and anesthesiology services.
[…]
She is still trying to figure out how much she has to pay out-of-pocket for the surgery and hospital stay -- and how much of that her insurance plan will reimburse. Payne said she believes the lab work, pathology, anesthesiology services and follow-up doctor’s visits were all covered. But recently she got a statement saying she was on the hook for $17,000 of the total cost of the surgery.

And that’s the rub, insurance never covers the full about and because most surgeons are “out-of-network” we have a higher co-pay which still puts it out of reach for many trans-people.

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If you live in the Hartford area there will be a discussion on how the ACA affects the LGBT community.