Friday, August 15, 2014

Health Insurance Coverage For Us!

At last our healthcare needs are being covered…
Oregon adds transgender procedures to Oregon Health Plan
Oregon Live
By Dana Tims
August 14, 2014

A full range of state medical coverage for low-income transgender people will be offered for the first time starting early next year.
The Health Evidence Review Commission, a 13-member board charged with setting Oregon Health Plan priorities, made that decision Thursday during a meeting in Portland.
The decision was hailed by advocates, who called it an historic step toward equality in medical care.
Some related services were added to the health plan last year. Those included psychotherapy, medical visits and medications to suppress puberty in gender-questioning youth.
Key new additions to the coverage include cross-sex hormone therapy and gender reassignment surgery.
But what does mean?

As more states, Medicare, and Medicaid require insurance coverage for us, no one knows what is actually covered; not the regulators, not the insurance companies, and not us.

Breast augmentation? Electrolysis? Facial feminization surgery? Chondrolaryngoplasty (tracheal shave)? It depends on who answers the phone; you can make ten different phone calls and get ten different answers. You can call the insurance commissioner’s office or the insurance company and get different answers. You could be told by the insurance company that it is covered but when you submit the claim it is denied.

Breast augmentation is usually not covered because it is considered cosmetic but with the proper codes it is medically necessary. So if you call the insurance company and ask if breast augmentation is covered the answer would be no, but is you ask if breast reconstructive surgery or medically necessary breast augmentation is covered the answer would probably be yes.

Then there is the coding by the doctor, many doctors have had no training in how they should code the procedures that they do for us. For example electrolysis maybe covered if the doctor says the procedure is for removing excess facial hair on women. Gender Confirming Surgery (GCS) is not just one procedure but a whole series of procedures, if the doctor codes GCS as one procedure it might not be covered. Most of the letters from the insurance commissioners say that the insurance has to pay for a procedure if it covered for cisgender people and that means that GCS does not have to be covered. However, if the procedure is broken down in to the different operations they are covered so it should also be covered for us.

The problem is that there are no policies on what it covered and what isn’t covered and there have been no guideline for doctors on how to code our medical needs, until that happens it is going to be hit or miss with insurance coverage.

A couple last things, I am not an expert on insurance coverage but I have talk to a number of experts and have followed their discussion online, and many of them are also confused on what should be covered and how to get that coverage. Those doctors who have been successful in getting coverage for their patients are telling other doctors on how to process the paperwork.

And second as most people know, insurance never pays 100% of the medical cost and many of the doctors are an out-of-network provider which means that we still will have a large out-of-pocket expense.

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