Insurance question to anyone who might know (Aetna)

[hmillerrr]

Hello guys,

How are you all? I hope everyone has somewhere safe and warm to be for the holidays.

I just wanted to see if anyone has had any experience with Aetna and trans surgeries etc. I've found some things but they're all out-dated. Whe n I look up top surgery and Aetna it gives a short list of requirements but I've heard that doesn't mean they actually cover it? I don't know... does anyone have any experience and advice on how to go about this whole thing? Thank you! 

[hmillerrr]

1 hour ago, gina-nicole-t said:

I have Regence Blue Cross and they have a huge list that I will post the .pdf to this so you can think about looking into if you desire. They are covering my breast augmentation and FFS in January. They have a long list of Gender codes they cover. I hope this helps you make a decision wether to stay with Aetna or change companies. 

Gina

Gender Dysphoria Codes for Regence.pdf 201.07 kB · 1 download

Thank you @gina-nicole-t I'm on my Dads insurance right now but I will definitely look into this. Thank you so much!

[hmillerrr]

Ps congrats!! I'm happy for you and I'm wishing you a happy, healthy, and quick recovery! @gina-nicole-t

[Audrey]

This is such an important topic. @hmillerrr, Aetna should have a policy document that lets you see very clearly what their policies will cover, and what the requirements are - similar to the ones Gina and I are linking here. Insurance companies are notoriously good about making information hard to find and understand, and remember that they are about making money first and providing healthcare second. You can try looking at a summary of benefits for a general overview, and sometimes it's helpful to talk to a real person if you can get through to one. Trans-friendly medical practices also often have experience working with insurance companies, so see if yours has a billing person, social worker, or someone with knowledge about this sort of thing that you could talk to.

 

I have Oxford / United Healthcare through my work. It's a good policy for healthcare in general, but it's lousy for transgender care:

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/gender-dysphoria-treatment.pdf

Basically, they'll cover hormones, and then they'll call everything else "cosmetic" until bottom surgery (and top surgery for trans men). That means no coverage for hair removal, facial surgery, breast augmentation, voice therapy/surgery, and so on for me as a trans woman. It's terribly regressive and exclusionary, and shows a profound lack of understanding about the actual experience of living with gender dysphoria. I think it also shows they know how high the requirements are for bottom surgery, and that they can save a lot of money by covering hormones only (which are cheap), knowing that relatively few people will ever meet the requirements for anything that will actually cost the insurance company anything. The climate in the U.S. is shifting for transgender care but very slowly. This is singularly motivating for me to change jobs, even before I know what coming out at my work will be like.

 

@gina-nicole-t, I'm so excited for your upcoming surgeries next month! I'll be cheering for you! ❤️

 

Love,

~Audrey.

[ValerieRun]

@hmillerrr what you want to do it get a complete list of all procedures covered by your specific policy. Aetna can cover some (or most) or none at all based on what limits they apply to your specific policy. Unfortunately, general benefits will not answer question, you need to find the list and they do not make it simple to discover. I had to do this research only to find my particular policy explicitly states that non of the gender-related processes are covered ?

You should be able to find this in the online account, but if you get lost, speaking to a representative would be next step, although it will out you to them as they will know the policy and members at that point.

[Jackie C.]

The easiest way to find out if a procedure is covered is to call your insurance provider and ask. They might have online resources but it's always best to get things from an agent directly. They can look up the specifics of your policy and tell you what's covered and what's not. They're also good for "super secret special insurance instructions" like, "It's covered, but only on a blood moon and your surgeon's name needs to start with an X." Or more realistically (and what I had to deal with), "Sure, but your surgeon needs to be in state."

 

Hugs!

[Elizabeth Star]

Thank you for the link to the list of codes. I haven't had much luck with my provider BCBSIL. All anyone will tell me is they cover anything that is "medically necessary". My insurance rep worked on it for over a month and got nowhere either. There is nothing, not even a reference to trans-care, anywhere in my policy or EOB.  They want me to provide them with specific codes for procedures, meds and diagnosis's then they'll tell me if it's covered.  I think it's crap and it'll probably be the death of me. If we were having a baby they would know all the answers of the top of their head but no, I'm just a trans-girl trying to get help. Thankfully I live in an informed consent state and was able to start HRT without the red tape.

[Joanne07081]

I am currently have health insurance coverage by Aetna through my employer. I am just starting back into transition so I am researching what they will cover (if anything). Any information that I can come up with I will post here, but from what I see it is difficult to get answers from them. 

[Maddee]

I recieved info from Aetna that DID cover all trans surgeries and even hair removal.  But this Aetna plan was employer specific.  I instead went with a Premera Blue Cross plan, thru same employer, that is looking like will cover things as well.  Working it out with a case manager this week.

 

Best luck in your research and transition.

 

[Jani]

That is the key.  While an insurance company may offer various coverage in its menu options, a private employer may decide not to offer certain elements to its employees due to cost or (perceived) lack of need.  Its always good to shop around if you can.  I hope it all goes well for you Maddee.  

[Carolyn Marie]

One thing to keep in mind, hon; in California, all insurance companies must, by law, offer coverage for trans health care.  That includes HRT and most forms of surgery.  They have the right to require a statement from your doctors that the procedure or medication is "medically necessary," but that is all they can require.  The sole exception that I am aware of is BA and/or FFS, but if your doctor is persuasive those should be covered too.  Best of luck.

 

Carolyn Marie