Is MTF surgery covered

[Guest Cody76]

By health insurance and if so how much has anybody here payed and how much would it be if not covered on insurance. Please answer honestly you don't have to sugar coat it I really want this done within a year or two.

[Guest KimberlyF]

Insurance companies are hit or miss. When I started to look this route, I found the specific policy my employer purchased to see what limitations were listed.

I have switched back and forth over the years between the two mine provides based on the need. One plan provided a superior selection of doctors, but did not cover baby wellness care, so we'd be able to pick which doctor made thousands off of our kid's immunization sched.

I believe knowing what you have and what you can have moving forward is important.

[Carolyn Marie]

Yes, it really does vary by state and by insurance company. A few states mandate coverage for trans health issues, but most don't. Some companies, regardless of state regulations, provide coverage. Anthem Blue Cross and Kaiser seem to be among the more progressive companies.

GRS, without insurance, is in the $18-30,000 range. Orchiectomies should be about half that. Surgery in Thailand is considerably less.

Here are two web sites with info on the subject:

http://health.costhelper.com/sex-reassignment-surgery.html

http://www.tssurgeryguide.com/Dr-Bowers-SRS.html

Carolyn Marie

[Guest LizMarie]

Generally, it's not a question of the insurance companies but a question of your specific policy. Since the vast majority of us get health insurance via our employers (a holdover relic policy from WWII that should have been discontinued clear back in 1946), we don't get much choice in health insurance. So you have to check with your health insurance provider and ask specifically about your policy.

Having said that, there are a small handful of states that have made coverage of GCS mandatory now. I'm not absolutely certain but I believe Colorado and California may now be in that camp. There may be a few others. Mainly I worry about my own backwards state, Texas, which will probably require GCS insurance support shortly after hades freezes over.

[Guest Melissa~]

I would add a few things. One: my cash quote from Dr Bowers of $24,500, that is however an expired quote. Secondly is coverage is dependent on your particular case too. A person is not likely to get coverage if they aren't cooperating with Dr's they work with etc.

My own coverage via insurance status is unknown, I'll find out soon.

[Guest Jo-88]

I just sent Kaiser an email asking about SRS coverage... I will see what they say. I know a lot of cali folks have kaiser so it will be nice to know.

[Guest Cody76]

Thanks girls all this is all very helpful and a bit of a relief I just didn't want to pay like $50k or something like that. I just hate having something where I really feel like there should be nothing but the hope that it will be gone is what keeps me going.

Love Christine

[Guest Jo-88]

I would love for SRS to be covered but I would prefer to go to Dr. Suporn because of his technique... so I would honestly rather wait as long as I have to until I can afford to pay out of pocket, because I doubt any insurance would cover an out of country operation. I just wish FFS was covered, for me it is 10000% more important than SRS... my face is "me" but my genitals are just part of me and get hidden behind my clothes anyway, out of sight out of mind (mostly).

[Guest kristendk]

At the moment, these five states require insurers to provide transgender coverage: California, Colorado, Connecticut, Oregon, and Vermont. (Reference)

Kristen

[Guest Jo-88]

At the moment, these five states require insurers to provide transgender coverage: California, Colorado, Connecticut, Oregon, and Vermont. (Reference)

Kristen

Unfortunately it is not as cut and dry as we want it to be... I can assure you that *most insurance policies in califorina still have 100% legal exemptions on transgender care. It all comes down to fine print and legal jargon, if a policy is worded correctly then can still deny you coverage. All it did was remove blanket it bans on transgender coverages... they can still have specific exemptions for specific treatments. The likelihood of surgery being covered is almost non existent... hormones may be covered but hormones are cheap and even then they may charge a higher co pay than normal. The insurance companies will fight this anyway they can because it is in their interests to do so and there is enough legal grey area for them to skirt around having to provide care.

I think very very few of us can ever hope to have SRS covered by insurance, that is a sad reality but it is the truth.

[Drea]

I know lots of people who had SRS covered by their insurance.

Even when policies had explicit exclusions.

The key factor is demonstrating medical need. If that can be demonstrated, and many can and do so, then coverage can often be obtained even when there is exclusion. Even without exclusion one may have to demonstrate need.

Like always with insurance they want to pay as little in claims as possible.

Unlike most big medical expenses in which the person undergoing the treatment rather avoid the procedure. Like who really wants to have open hear surgery, chunk of lung removed, chunk of intestines removed. There are also tests that make clear such procedures are required. With SRS, the diagnostic criteria is very soft, the clients actually want the procedure, yet many with the same condition don't want the procedure and there are even those who express feelings like "it isn't a big deal for me, I wouldn't have surgery if I had to pay, but if it was free I would". So for someone like that, is it a medical need? Makes it harder for the folks with medical need.

[Carolyn Marie]

I can assure you that *most insurance policies in califorina still have 100% legal exemptions on transgender care. It all comes down to fine print and legal jargon, if a policy is worded correctly then can still deny you coverage.

I can't say how many companies in CA still have legal exemptions, because I am not familiar with all of them. Two of the largest, Kaiser and Anthem Blue Cross, cover all treatments including surgery, if one demonstrates medical necessity. My reading of the new regulations is that an insurance company would have to clearly show that a request for surgery was not a medical necessity. If one is denied coverage, they have the right to appeal first within the insurer, and then to the state. The burden really is on the insurance company now, to justify a denial.

Carolyn Marie

[Guest Jo-88]

I am still waiting to hear back from kaiser... but on my benefits summary transgender care is specifically excluded, but then again they are covering my HRT and labs so idk. Fingers crossed, I will report back.

[Drea]

I am still waiting to hear back from kaiser... but on my benefits summary transgender care is specifically excluded, but then again they are covering my HRT and labs so idk. Fingers crossed, I will report back.

Is this a simple abstract inquiry if they will cover surgery?

Or is this an actual pre-approval request for coverage of SRS with supporting documentation from doctors stating medical need, referral letters, etc?

I ask because if it is the former the odds are that they will say no. Even when there is supporting documentation for non-trans related procedures, even something as simple as having an MRI insurance companies often deny pre-approvals on the first request hoping there won't be a challenge and the person will go away. So even if it is the latter, the first answer is even likely to be a denial, but that is by no means the final word.

I know of more than a few who received initial denials who eventually got coverage and that included ones who had policies that specifically excluded transgender surgeries. The key is the doctors need to demonstrate the medical need.

I draw a parallel about how the requirements SRS surgeons have. They have their perfunctory requirements on their web site and stated by their staff that reflects and conforms to what everyone "knows" such as living full time, one year RLE, so long in therapy, etc so they don't get a steady stream of folks insisting that they need SRS before going full time or how unfair a burden 1 year RLE is without SRS, etc. When the reality is they are far more flexible on any of those points if one's doctors make a good case for bending any of those and in fact, something like the 1 year RLE is fairly commonly bent allowing shorter periods.

[Carolyn Marie]

Just a follow up here. My son just enrolled in a personal policy under Anthem (he used to be under my family plan) and we received the (huge) booklet on benefits. The exclusion for gender/sex change, which I had always seen before, is nowhere to be found. That is in compliance with the new state regulations.

Carolyn Marie

[Guest Jo-88]

I am still waiting to hear back from kaiser... but on my benefits summary transgender care is specifically excluded, but then again they are covering my HRT and labs so idk. Fingers crossed, I will report back.

Is this a simple abstract inquiry if they will cover surgery?

Or is this an actual pre-approval request for coverage of SRS with supporting documentation from doctors stating medical need, referral letters, etc?

I ask because if it is the former the odds are that they will say no. Even when there is supporting documentation for non-trans related procedures, even something as simple as having an MRI insurance companies often deny pre-approvals on the first request hoping there won't be a challenge and the person will go away. So even if it is the latter, the first answer is even likely to be a denial, but that is by no means the final word.

I know of more than a few who received initial denials who eventually got coverage and that included ones who had policies that specifically excluded transgender surgeries. The key is the doctors need to demonstrate the medical need.

I draw a parallel about how the requirements SRS surgeons have. They have their perfunctory requirements on their web site and stated by their staff that reflects and conforms to what everyone "knows" such as living full time, one year RLE, so long in therapy, etc so they don't get a steady stream of folks insisting that they need SRS before going full time or how unfair a burden 1 year RLE is without SRS, etc. When the reality is they are far more flexible on any of those points if one's doctors make a good case for bending any of those and in fact, something like the 1 year RLE is fairly commonly bent allowing shorter periods.

It is just an inquiry... not an actual request. I am minimum 2 years away from seeking SRS (probably longer). But I want to see the legal language that they are using.

[Guest Jo-88]

This was the response I received from Kaiser.

"Thank you for your message to our Web site.

You are covered under a group plan and the employer chooses which coverages they will offer their employees.

Your employer chose not to offer this coverage.

The law pertains to Individual Plans."

So there you go, legal exclusion of transgender care in the state of California.

[Guest Jenni_S]

That's generally how it is. The entity paying for the coverage chooses what to cover. If they so choose, they can decide to only cover catastrophic events costing more than X amount of dollars, or what have you. It's easy to forget, but consider what you *are* getting from what your employer is paying for, and how much that would cost on your own. There's always the option to pick up something individually for what isn't covered.

In the position I have with my employer, I know exactly what it costs to cover the employees; it's not cheap. It easily exceeds what I could afford to pay on my own. Keep in mind what you're getting besides your paycheck, I'm pretty grateful that I have that insurance from my employer.

It's also entirely possible that your policy will cover procedures deemed medically necessary. If it does, your letters from therapists should say that it is. Having that documented often opens doors, it did for me. General exclusions are just that, for things in general. Specific cases with documented medical need can, and do, depending on all that fine print, can override the general exclusions.

[Guest Jo-88]

No question about that at all Jenni, my plan is actually very good and I don't pay much for it... I think its like $120 out of my paycheck and I have really low deductibles and out of pocket maximums. It would be nice if it covered SRS but for general health coverage I have no complaints.

[Drea]

There are at least two people who have commented in this topic where their insurance the exact type of exclusion as in your policy who were still able to get their surgery covered.

If your objective was to demonstrate that a policy in CA can still exclude trans surgeries and why you have gotten an answer.

If your objective was to get a definitive answer as to them covering it or not, I would say their response is predictable yet really is in no way indicative if they will really cover it or not. If the need can be demonstrated, and I think it is really easy to meet that standard if one is seeing a therapist as the surgeon is going to require. That should be fairly easy. So I think the odds are still pretty good.

I understand you are looking out of the country so it might not cover that anyways.

[Guest Jo-88]

There are at least two people who have commented in this topic where their insurance the exact type of exclusion as in your policy who were still able to get their surgery covered.

If your objective was to demonstrate that a policy in CA can still exclude trans surgeries and why you have gotten an answer.

If your objective was to get a definitive answer as to them covering it or not, I would say their response is predictable yet really is in no way indicative if they will really cover it or not. If the need can be demonstrated, and I think it is really easy to meet that standard if one is seeing a therapist as the surgeon is going to require. That should be fairly easy. So I think the odds are still pretty good.

I understand you are looking out of the country so it might not cover that anyways.

I agree, like I said I was just looking for their official response not a de-facto answer on whether it can be covered or not. I just wanted people to know it isn't as cut and dry as we all hope it to be. There is always a chance that if you can prove medical need that it can be covered.

[Guest Melissa~]

Just a follow up here. My son just enrolled in a personal policy under Anthem (he used to be under my family plan) and we received the (huge) booklet on benefits. The exclusion for gender/sex change, which I had always seen before, is nowhere to be found. That is in compliance with the new state regulations.

Carolyn Marie

Ditto with my insurance, back when I started there was a TS treatment exemption. Poof it the exemption disappeared after a while. I can anecdotaly say I haven't had any treatment I applied for turned down yet.

I haven't tried for laser or electrolysis coverage.

My SRS claim is pending.

I'm tempted to try for BA too, as a one time thing, (too bad BA isn't a once and done thing for life.) If I was done growing as of right now I'd want BA, but I dunno the extent of where I will wind up, so it's going to slide for now.

[Carolyn Marie]

I'm tempted to try for BA too, as a one time thing, (too bad BA isn't a once and done thing for life.) If I was done growing as of right now I'd want BA, but I dunno the extent of where I will wind up, so it's going to slide for now.

I haven't tried for laser or electrolysis coverage.

I would be very surprised if any insurer covered BA, facial hair removal or FFS. I believe nearly all policies have a blanket restriction on cosmetic surgery, and those I mentioned are normally considered cosmetic procedures. One can argue otherwise, but it would be an uphill fight. Not even the IRS will allow medical deductions for those procedures.

Carolyn Marie

[Guest Melissa~]

Bump!

My Surgery -is- being covered by my insurance.

[Guest KimberlyF]

Bump!

My Surgery -is- being covered by my insurance.

Congrats

More money to spend on Legos!