Insurance approval – Gender Confirmation

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  • Some of the most stressful questions come up when trying to figure out insurance coverage for gender confirmation surgery. you are not alone if you are looking at your google search history and see:

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    • We are here to provide some guidelines to help answer some of these questions. Your first step is to contact us for a consultation. we have an insurance concierge who works directly with your insurance provider to see what transgender health insurance benefits you have.

      Our insurance defense team will guide you through every step of the insurance approval process until approval is achieved or when it becomes clear you don’t have coverage. Because one of our primary goals is to have your gender confirmation surgery covered by insurance, we provide insurance defense work as a free service to all of our patients to give everyone the best chance of success.

      Our team has experience obtaining insurance approvals for our surgeons to work with the following insurance providers:

      • aetna (student services only)
      • anthem (national and california)
      • brown & toland hmo
      • health network
      • safe
      • blue shield
      • national airline
      • hills doctors (hmo)
      • excellus (blue cross/blue shield of new york)
      • united health care
      • To help us verify benefits, we will need the following information from you:

        • full name
        • date of birth
        • procedure(s) you wish to cover
        • a scanned copy of your insurance card (front and back)
        • your contact number (where we can also leave a message)
        • Once we have your information, we will contact the insurance company and let you know as soon as we hear from them. when we contact you, we will present one of the following scenarios:

          situation a: your insurance company does not cover the cost of your procedure(s). some options you will have if this happens:

          • Paying out of pocket for the procedure
            • The lack of health insurance for gender confirmation procedures is an unfortunate reality for some. . rest assured that you are not alone in this process; reach out to your community for support and guidance.
            • finance your procedure(s) with carecredit
              • works like a credit card but is exclusively for health services. You can use it at any health care service, including gender confirmation surgeries in San Francisco and beyond. Will it cover your higher surgery costs? this depends on the amount for which it has been approved. visit the carecredit website for more information.
              • financing your surgery with a loan
                • a loan may be in your best interest if you are unable to get your gender confirmation surgery covered by insurance, if your surgeon of choice not if you don’t accept insurance, or if you don’t feel comfortable or can’t enroll in carecredit.
                • There are several types of loans specifically for gender confirmation surgery procedures.
                • If scenario a occurs, our team will help you explore the two options listed above.

                  California law prohibits insurance companies from denying health insurance benefits for transgender-related care. however, there are two exceptions:

                  1. if the policy is a large group that is ‘self-funded,’ meaning the employer bears the direct risk of paying claims or benefits (not the insurance company), these policies are not required by law to have health insurance benefits that cover gender confirmation surgery.
                  2. If the employer’s corporate office is located in a state other than California, the health benefits policy is governed by the laws of the state where the corporate office is located.
                  3. scenario b: your health insurance covers gender confirmation surgery

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                    This scenario can be divided into two possibilities:

                    Possibility #1: Your insurance is with Anthem Blue Cross, Blue or Brown Shield & to land. our practice has agreements with these providers, so your approval process should be seamless and straightforward.

                    what we will need from you for authorization approval:

                    • a letter from a mental health provider stating that you meet the general guidelines for surgery
                    • notes of your consultation with our surgeons that we will have ready 1-2 days after your consultation
                    • referral to our practice from your primary care provider (if you have an hmo or are getting your insurance through a school)
                    • There may be additional requirements based on individual circumstances.

                      once we receive the necessary documents, we will begin the authorization request immediately! it takes 4-6 weeks to get a response from insurance providers we have an agreement with.

                      Possibility #2: You have health insurance that covers gender confirmation surgery, but our surgeons do not have an agreement with these providers

                      There are a couple of ways to cover your surgery, even if our practice doesn’t have an agreement in place with your company:

                      1. our office can obtain a loa (letter of agreement) for a single case with your provider. this is usually a single contract between us and your insurance, for this procedure, just for you.
                      2. In the rare cases where a loan cannot be obtained, you will pay up front and then we will continue to seek reimbursement after your surgery. In this case, you would receive a refund from your insurance plan later (minus a 6% administrative fee from our billing company. That’s the percentage they charge the gcc to file a claim).
                      3. Your insurance would treat this as “out of network”. It’s still beneficial to go through the authorization process because it can greatly reduce your hospital expenses, and your insurance will usually pay a portion of the surgery.

                        What are some insurance companies that cover gender confirmation surgeries?

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                        It is important to note that there is no “one” insurance company that is “best” when it comes to covering transgender health care. however, over the years of working with different insurance companies that cover gender confirmation surgeries, some companies have a higher trend of approvals versus denials. Insurance approval for gender confirmation surgery is based on a variety of factors that could disqualify a patient for approval, no matter how “good” her insurance is. remember, you will want to find a surgeon that accepts your insurance. These factors include:

                        first, is the coverage:

                        1. the patient must have grs benefits in his plan
                        2. network qualifications: If a patient does not have an out-of-network benefit and the loan requested in the office is denied, then the insurance denies the case.
                        3. second, if a patient meets the gender affirming care guidelines, most insurances have the same guidelines they follow with wpath and this is where the support letter comes into play.

                          The larger companies we accept that have seen decent insurance approval rates are:

                          • old blue cross
                          • blue shield
                          • aetna
                          • cigna
                          • united medical insurance
                          • anthem blue cross blue shield medical
                          • If you have prior health insurance and are looking for gender confirmation surgeons outside of our practice, try looking up which surgeons are in-network with your health insurance plan. or contact your insurance provider directly to see if they have information to guide you.

                            It can be exciting to be enrolled in health insurance that covers gender confirmation surgery. After reviewing your policy, you may even find that you have the best transgender healthcare insurance. but when it comes down to it, they might not have qualified surgeons in their network.

                            Your insurance provider is required by law to refer you to a surgeon who can perform the procedure.

                            Getting approved can seem like an overwhelming process. however, with the help of our experienced staff, you will be able to maximize your insurance benefits without hassle or stress.

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