I Am Getting Tired

I am getting tired of fighting battles and winning but only to have to fight the battle of red tape. Insurance companies have a favorite word… “NO!”

They are experts in putting up road blocks or changing the rules in the middle of the stream or the “Yes but…”

Many times we transition because the alternative usually ends up with our death.

To be herself, she needs to change her body. But first, comes the battle with insurers
CNN
By Emanuella Grinberg, Alice Kantor and Christina Walker
May 31, 2018

"I was trying to drink myself to death to escape who I was," she said. "I wasn't allowed to be myself, so I didn't want to be anyone else."

Then, at 35, she realized what she needed to do to be herself: accept that she's transgender and live openly as the woman she always knew she was.

To do that, she said, she had to "fix" her body. But after the battle with herself came the battle with insurers.

We were so happy when here in Connecticut the insurance commissioner issued Bulletin IC-34 ordering insurance companies to give us the same coverage non-trans people receive*.

Then we found out that it doesn’t cover Medicaid (it does now) or as it is called in Connecticut Husky.

Then we found out that it didn’t cover Medicare (it dos now).

Then we found out it did not cover ERISA (it still doesn't) insurance coverage.

Jasmine began taking hormones in 2012, before she had insurance, paying out of pocket. In 2014, she got on a Michigan Medicaid plan offered by Priority Health. For the past four years, she's been fighting to get coverage for vaginoplasty and facial feminization. Her doctors say the surgeries are medically necessary to treat her gender dysphoria -- the diagnostic term for the distress she feels over the conflict between her gender and the sex she was assigned at birth.

When you are trans you need to become very good at advocating for yourself, if you don’t, if you just sit back and take “No” for an answer you will be shut out of proper medically necessary treatment.

The insurance companies are so good at throwing up roadbocks.

 After rounds of appeals, she won pre-authorization for vaginoplasty but not a prerequisite hair removal procedure. After she was approved for hair removal and started treatments, her pre-authorization for vaginoplasty expired. Priority declined to again pre-authorize the surgery in 2018 on the grounds that it was no longer a benefit. Now, she is appealing the denial for vaginoplasty while her battle continues for facial feminization surgery.

"Apparently, I am getting hair removed for prep for a surgery I now can't get," she said. "This crap is why I wish I were dead."

Roadblocks to roadblock,

Two others, Medica and Oscar, said they did not cover such procedures because they were not included in a state's Essential Health Benefits, a set of services insurers are required to cover under the ACA. Nothing in state or federal law precludes insurers from offering benefits that are not spelled out in a state's Essential Health Benefits. But in a state without explicit anti-discrimination mandates, health care experts say there's little incentive for an insurer to be the only one offering gender-affirming benefits -- especially if no one is holding them accountable.

Even in states with protections they still stall and hope you will go away.

The trade association America's Health Insurance Plans (AHIP) said carriers comply with state and federal laws and work to ensure that members have access to services they need. If a patient encounters barriers, "we would encourage them to have conversations with their health care plans to help ease the path to access to care," said Cathryn Donaldson, communications director for the association.

Another roadblock that they put up in front of us is that we have to have it done “in state” and many times there’re no doctors who do Gender Confirming Surgery (GCS) in your state or they do not do the procedure that you want or they have a bad reputation.

Then the biggie they throw in front of us is that the doctor is “out-of-network” and you need to come up with twenty thousand dollars before you can have surgery, or at the very least you need to pay a higher co-pay.

So yes, we do not have insurance but good luck in getting coverage for GCS

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*If you breakdown GCS you will find that it is made up of a series of operation that are covered by the insurance companies.

Anthem Blue Cross/Blue Shield bulletin  CG-SURG-27 says,

Cosmetic:
The following procedures are considered cosmetic when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo sex reassignment surgery, including, but not limited to, the following:

Abdominoplasty
Blepharoplasty
Breast augmentation
Brow lift
Calf implants
Face lift
Facial bone reconstruction
Facial implants
Gluteal augmentation
Hair removal (for example, electrolysis or laser) and hairplasty, when the criteria above have not been met
Jaw reduction (jaw contouring)
Lip reduction/enhancement
Lipofilling/collagen injections
Liposuction
Nose implants
Pectoral implants
Rhinoplasty
Thyroid cartilage reduction (chondroplasty)
Voice modification surgery
Voice therapy

It nice list but…

They do cover brow lifts, face lifts, facial bone reconstruction, facial implants, hair removal, and voice therapy when it is medically necessary for cis gendered individuals.

They cover facial hair removal for women with hirsutism so some trans women have been getting electrolysis covered if all their medical records say they are female and that it is “medically necessary.”

The same is true for voice therapy if it is “medically necessary.”

So don’t take no for an answer… fight!