Anthem Blue Cross California has released information regarding the coverage of medically necessary procedures to treat gender identity disorder, commonly referred to as a person being transgender. Effective immediately, all new and grandfathered plans will cover surgeries, hormone therapy and counseling associated with transitioning from the birth sex to the sex the individual identifies with.
Good overall review of benefits
Blue Shield of California had released amendments to their plans earlier in the year addressing the coverage for transgender benefits. The Anthem Blue Cross “Frequently Ask Questions” about the new coverage is far more in depth, explaining how they will handle the coverage. From the FAQ which can be downloaded at the end of this post.
Q. What is a transgender person?
A. A transgender person is an individual that meets any of the following criteria:
(1) a person who has, or has been diagnosed with, gender identity disorder or gender dysphoria;
(2) a person who has received health care services, including counseling, related to gender transition;
(3) a person who adopts the dress, appearance, or behavior of the opposite sex; or
(4) a person who otherwise identifies himself or herself as a gender different from the gender assigned to that person at birth.
Q. What is gender transition?
A: Gender transition means the process of changing one’s outward appearance, including physical sex characteristics, to accord with his or her actual gender identity. Not all individuals who undergo gender transition will opt to complete the full transition with surgery. Members are now eligible for a spectrum of gender transition services along the treatment continuum.
Medically necessary diagnosis, treatment
To be eligible for the covered transgender benefits the health insurance policy must originate in California. A California policy covering employees outside of the state will qualify for services. California residents insured by an Anthem Blue Cross plan originating in another state will not be eligible for benefits. Cosmetic surgery will not be covered.
Selected services provided for gender identity dysphoria.
|Hormone Therapy||Androgen or estrogen|
|Hormone blockers||Aromatase inhibitors or Gonadotropin-releasing hormone analogues|
|Mental health||Counseling, psychotherapy|
|Preventive screenings||pap tests, prostate, mammograms, breast exams|
|Laboratory screenings||Blood tests for: hormone levels, cholesterol, liver|
|Urethroplasty/Urethral reconstruction||Reconstruction or rerouting of urethra|
|Mastectomy||Removal of breast tissue|
|Hysterectomy||Removal of uterus|
|Phalloplasty||Construction or penis|
|Vocal training||Outpatient speech therapy|
|Travel||$10,000 travel amount maximum for complete surgery for clinics >75 miles. *Prior approval required|
|This is not a complete list.||Some benefits require prior approval.|
Transgender benefits in California only
The incorporation of transgender health reassignment benefits applies to all individual, family, small group and large group plans. It does not apply to self-funded plans where Anthem Blue Cross is the Administrative Services Organization. Transgender benefits will be included in all new Covered California health plans that become effective January 1, 2014.
Some health plans may lag
Because this is a California state law that pertains to plans managed by the California Department of Managed Health Care and the California Department of Insurance, all health insurance plans will need to cover the transgender benefits. Anthem noted that all requests for services must be manually entered as they update their system to handle the procedures and codes. Expect similar issues with the other insurance carriers.
Communication is key for smooth transition
If you are considering using these new health insurance benefits to transition, contact your health plan first and see exactly how they are going to handle the benefits. We know that you will need a diagnosis of gender identity disorder or gender dysphoria. Some plans may want to approve a treatment plan in advance. The communication you and your doctor can have with the insurance company, the fewer hassles you will encounter.
Transgender Success Story
A client recently reported that his Anthem health plan did authorize some surgical procedures for his transition. Of the two requested surgeries, one was considered medically necessary and the other was deemed cosmetic. Here are a few of his tips to navigating the insurance maze to get transgender health benefits for transition covered.
- Ask a lot of questions since there is much confusion surrounding trans benefits and it’s hard to immediately tell what is covered or not.
- Seek professional help from specialists like Kevin Knauss who will go out of his way to help you navigate this insurance maze.
- Tell your doctors in California that even where there is no explicit trans benefit, many procedures will be covered with prior authorization if deemed medically necessary so have strong letters from your therapists, doctors and endocrinologist stating that your procedures are “medically necessary” so that they can get covered.
- Be aware that your surgeon and their insurance department are likely as confused as you are about the new trans law so you have to educate yourself and them as well.
- Anthem seems to be the most trans aware insurance at present in Cali as many people have been able to get procedures covered with them so fight your insurance companies, file appeals where necessary but also be willing to change to progressive insurance like anthem if necessary.
Transgender Health Benefits Remain Elusive
Blue Shield Medical Policy on sex reassignment surgery
2016 Anthem Blue Cross Nondiscrimination of Transgender Health Care Services
[wpfilebase tag=file id=1604 /]
[wpfilebase tag=file id=1603 /]
Other blogs on transgender health benefits