Insurance for Surgery 101


Know that every transgender procedure- from bottom surgery to facial feminization surgery- has been covered by private plans and medicaid plans in some contexts. This guide will help you take the first steps to finding out what your plan covers.

How do I know if my plan covers surgery?
 

One person’s “United Healthcare” plan is not the same as another person’s “United Healthcare” plan. One might cover trans surgery and one might not. The name of the insurer does not tell you anything about coverage.

  • The specific rules about what must be covered (and the way to fight an insurance company that is not following those rules) changes depending on the mix of state and national regulations that apply to that plan. Three people who all live in the same state could have three different “Blue Cross Blue Shield” plans that are governed by different rules.

    • Public insurance: medicaid or managed medicaid plans administered by different insurers (ie BCBS Managed Medicaid)

    • Fully funded private plan: plans the must follow local state regulation

    • Self-funded private plan: a category of plans that do not follow state regulation

  • The Affordable Care Act adds protections on a national level, to all plans. The ACA states insurers should not deny a claim just because of the gender marker listed on your insurance. This is especially useful for appealing denials of claims for trans people who need care related to their reproductive systems (gynecology, urology, reproductive health).

  • Familiarize yourself with the costs associated with any covered procedure through your insurance. Do you have a deductible to pay before the plan starts to pay? A co-insurance after that? What's your out-of-pocket maximum? Do you have out-of-network benefits, and do those numbers change (and/or reset) for out-of-network providers?

Ok, so it’s complicated. Then where do I start?

If you are uninsured, check out ou2enroll to learn what trans inclusive insurance might be available to you.

If you are currently insured, use your insurances online portal or call and ask to be sent a paper copy of your plans “Certificate of Coverage.”

  • This document overrides what any representative tells you on the phone. 

  • This document could lay out very explicitly which trans surgeries are covered and what is needed in order for your claim to be approved.

  • This document might violate state or other regulation in the way that it denies coverage. In that case, you very likely need legal assistance to continue
     

This is too confusing. I hit a snag. I need help.

There is no need to do this alone. Ideally, a surgeon’s office is helping you navigate your insurance coverage and the appeals process. They submit a prior authorization containing details about what surgery is being performed, along with supporting documentation like letters of support from mental health providers. The insurance company approves or denies the claim, and from there you can begin to appeal a denial. I tell everyone to plan for an initial denial. Please see the resource guide for organizations that could offer more specific legal help with the appeals process. It’s also a good idea to contact local LGBT centers and organizations to see if anyone local to you is working to help people in your area.