Insurance

The most calls that I get at the non-profit where I volunteer are about insurance coverage.

We are pretty good here in Connecticut for insurance coverage… but.

Sometimes the insurance companies don’t follow the law. Surprise, surprise!

If you are covered by Medicare,

Medicare for transgender-related health care
Market Watch
By Home Media
February 8, 2021


What you should know:

• 1.4 million adults in the United States identify as transgender
• Hormone therapy typically costs $100 per month
• Gender affirmation surgery usually costs between $7,000 and $50,000
• There are approximately 10,000 transgender Medicare beneficiaries [I’m one of the 10,000]
• Medicare covers medically necessary transgender surgery on a case-by-case basis
• Those insured through Medicare are more likely to get transition-related surgery than those with private insurance

[…]
For the relatively small number that qualifies for Medicare coverage — just 0.7% of transgender people are Medicare beneficiaries — Medicare can provide significant relief. Medicare ensures that medically necessary care is covered, including some gender confirmation procedures.

It wasn’t until 2014 that we were covered legally, healthcare providers knew how to navigate around the roadblocks and I had my healthcare covered.

Medicare transgender coverage
For decades, Medicare specifically excluded transgender surgery and related procedures. Anyone attempting to get Medicare transgender coverage was denied because the procedures were deemed “experimental.”

In 2014, the Centers for Medicare & Medicaid Services issued a new determination that removed the existing exclusion for transgender surgery. Now, Medicare will determine coverage of transgender-related procedures on a case-by-case basis.

In addition, Medicare must cover routine preventative care if it’s clinically necessary, regardless of the gender marker on your Social Security records. If there is a potential for gender mismatches between your records and gender identity, the physician or hospital should use billing code (condition code 45) to help process your claims.

Most important… “the physician or hospital should use billing code (condition code 45) to help process your claims.” that is my mantra! Just about every year when I have my annual physical my doctor checks my prostrate and the insurance company sends out red flags saying women don’t get prostrate exams denying the charge. I keep saying “Code 45!” until it dawns on someone and the charge for the exam is paid.

This is important…

What to do if you’re denied coverage
If your request for health-care services or procedures is denied, you have the option of appealing that insurance company’s decision and requesting a redetermination.

If you have Original Medicare, complete the Redetermination Request Form and send it to the company that handles your Medicare benefits. In the request, include your name, address, and Medicare number. Circle the items you disagree with and include a written explanation of why you think the items should be covered. Include any supporting documentation, such as medical records or statements from your doctor.

If you are on a Medicare Advantage plan, you typically have 60 days after receiving a denial to file an appeal. While some plans allow you to appeal over the phone, others require you to appeal in writing, so make sure you check your insurance company’s policies.

If you’d like to consult a licensed Medicare professional before selecting the Medicare coverage that’s right for you, call 844-259-6504 and ask about Medicare for transgender-related health care.

Denial of coverage is the number one problem I hear. I usually tell them to call back and get a different operator and amazingly that works a lot of times. Also be careful how you phrase the request, for example do not say that you want “breast enlargement” rather say something like that you need medically necessary breast surgery.

Here in Connecticut we have a few more tools in our tool box, the first is CT Insurance Commissioner Bulletin IC-37. What the bulletin does is require insurance companies to pay for any medical procedures that they cover for non-trans patients. So that means that they pay for medically necessary breast surgery for cancer patients so they have to pay for us also. Even electrolysis is covered! It is called Hirsutism (ED72 ICD-11) which is covered and it should also be covered for us.

The other tool in our tool box is a declaratory ruling by the Commission on Human Rights and Opportunities… DECLARATORY RULING ON PETITION REGARDING HEALTH INSURERS’ CATEGORIZATION OF CERTAIN GENDER-CONFIRMING PROCEDURES AS COSMETIC. What the ruling does is tell the insurance companies to obey the law.

V. CONCLUSION
The complexity that transgender people face in evaluating their own gender identity and sex requires that doctors, insurers, and the State recognize them as the individuals that they are. Just as disregarding the individuality of a person on the basis of their skin color strikes at the heart of antidiscrimination policy, painting all transgender people with the same brush violates that same principle. Insurance policies that categorically refuse to consider certain procedures for certain people on the basis of their race, sex, or sexual orientation are facially discriminatory. So too are such exclusions for transgender people on the basis of gender identity, a condition unique to them. Consequently, when the State or a municipality contracts for health insurance plans that contain categorical exclusions for treatments related to gender dysphoria – and especially when the same treatments are covered for treatment of other conditions – it commits a discriminatory practice, as does the insurer.

Transgender people are uniquely reliant on medical services to help them treat gender dysphoria – to avoid both personal distress as well as future violence and discrimination. The State cannot permit itself, its agents, and its municipalities to discriminate against this vulnerable group of people. Our understanding of sex and gender has evolved. It is time for the State to catch up, and reclaim its place on the front lines in the fight against discrimination on the basis of gender identity or expression.