Anthem Blue Cross of California has included a section called Transgender Services in their Evidence of Coverage (EOC) documents for individual and family plans offered in California for 2015. While the seven paragraph section doesn’t provide a lot of details, it is a major step toward recognizing that individual plans must include such coverage to address the medically recognized gender dysphoria or gender identity condition.
Transgender Service Evidence of Coverage
The Evidence of Coverage (sometimes referred to as the Member Agreement or Certificate of Coverage) is the contractual agreement between the insured and the health plan member. The EOC spells out what is included and excluded from covered benefits along with the responsibilities of both the insurance plan and the member. Whenever there is a question about whether a medical procedure, service, or therapy is covered, the EOC is the rule and guide book for both the member and the insurer.
“Your plan doesn’t cover transgender services”
Countless times I have been contacted by people who complain that when they called their California insurance company and were told that their health plan does not cover transgender services. But we all know that under California’s Insurance Gender Nondiscrimination Act it is mandated that health insurance must cover hormone replacement therapy and certain sex reassignment surgeries to address documented gender identity conditions. Now, at least for Anthem Blue Cross members, they can point to the exact language in the EOC to refute any initial denial of services.
Evidence of Coverage rule book
Not all EOCs are readily available for examination prior to purchasing a health plan. Blue Shield has posted their EOCs on their internal agent website (many of their EOCs can be found on my Blue Shield page). Blue Shield has no mention of transgender services in their EOCs that I can find and Kaiser mentions only that they don’t discriminate on the basis of sex, gender identity, gender expression, or sexual orientation. Some carriers refuse to make an electronic version of the EOC available to the public.
Anthem Blue Cross Transgender language
Anthem Blue Cross doesn’t make the EOCs easily available, but as an agent I can download Blue Cross EOCs attached to an existing client. Consequently, I don’t have all the EOCs for all the individual and family plans offered in California. While reviewing one of the 2015 Blue Cross EOCs about another issue I tripped across the transgender language for their Gold PPO Multi-State plan.
Precertification is required for certain Transgender Services (see the part GETTING APPROVAL FOR BENEFITS for details).
Benefits are provided for services and supplies in connection with Gender Transition when a Physician has diagnosed You with Gender Identity Disorder or Gender Dysphoria. Benefits are provided according to the terms and conditions of this Agreement that apply to all other medical conditions, including Medical Necessity requirements, Precertification and exclusions for Cosmetic Services.
Coverage includes, but is not limited to, Medically Necessary services related to Gender Transition such as transgender surgery, hormone therapy, psychotherapy, and vocal training. Coverage is provided for specific services according to benefits under this Agreement that apply to that type of service generally, if the Agreement includes coverage for the service in question. If a specific coverage is not included, the service will not be covered. For example, transgender surgery would be covered on the same basis as any other covered, Medically Necessary surgery; hormone therapy would be covered under this Agreement’s Prescription Drug benefits. Services that are excluded on the basis that they are cosmetic include, but are not limited to, liposuction, facial bone reconstruction, voice modification surgery, and hair removal.
Some services are subject to prior authorization in order for coverage to be provided. Please refer to the part GETTING APPROVAL FOR BENEFITS for information on how to obtain the proper reviews.
Transgender Surgery Travel Expense. Certain travel expenses incurred by the Member, up to a maximum $10,000 Anthem payment per transgender surgery or series of surgeries (if multiple surgical procedures are performed), will be covered. All travel expenses are limited to the maximum set forth in the Internal Revenue Code, not to exceed the maximum specified above, at the time services are rendered and must be approved by Anthem in advance.
Travel expenses include the following for the Member and one companion:
Ground transportation to and from the approved facility when the facility is fifty (50) miles or more from the Member’s home. Air transportation by coach is available when the distance is three-hundred (300) miles or more.
When You request reimbursement of covered travel expenses, You must submit a completed travel reimbursement form and itemized, legible copies of all applicable receipts. Credit card slips are not acceptable. Covered travel expenses are not subject to the Deductible or Copayments. Please call Customer Service at 1-855-634-3381 for further information and/or to obtain the travel reimbursement form.
Travel expenses that are not covered include, but are not limited to: meals, alcohol, tobacco, or any other non-food item; child care; mileage within the city where the approved facility is located, rental cars, buses, taxis or shuttle services, except as specifically approved by us; frequent flyer miles, coupons, vouchers or travel tickets; repayments or deposits; services for a condition that is not directly related to, or a direct result of, the transgender procedure; telephone calls; laundry; postage; or entertainment. – pages 106, 107 for plan number 1G08, Gold PPO Multi-State, CA_DMHC_MSP_0_PPO_(1/15)
This text is found in other individual and family plan Anthem Blue Cross EOCs that I have reviewed as well. Interestingly, the Multi-State plan has nothing to do with the plan benefits being honored in other states. The purpose of the Multi-State plans, under the ACA, is to have some health plans that conform to certain federal regulations for covered health care services. The notable distinction of Multi-State plans is that, like federal health plans, they will not cover elective abortions. See: Multi-State health plan abortion restrictions
Equality transparency and disclosure
Either way, the inclusion of the transgender services language answers the question for many Anthem Blue Cross customer service representatives as to whether the health plan includes benefits for sex reassignment surgery. We are inching our way toward full disclosure and transparency in the contracts between the insurers and the members so that consumers can finally see what is truly covered in their health plans.
Download Anthem Blue Cross Gold PPO Multi-State Evidence of Coverage document
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