Transgender Health Insurance (Part 2): Why Coverage Is Only the Beginning

When I learned that my insurance would pay for my top surgery, I thought the deal was sealed, but I faced two unanticipated limiting factors while preparing for surgery: (1) finding a surgeon willing to work with insurance, and (2) fitting the profile of a "properly" insurable trans person.
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When I wrote my previous entry in this series, I was still waiting to hear whether my insurance company would cover my chest reconstruction. Read about it here.

Takeaway #1: Policy Changes Are Only the Beginning of Necessary Reforms

My health insurance covered my top surgery -- all $8,000 of it. It took a year of self-educating, anxious waiting, obtaining provider letters, heartache at an initial rejection, and intense bursts of communication between my university, my insurance company, my surgeon, and me. The feeling of relief was unforgettable as I opened my mail to finally find an affirmative response to my appeal.

Since then I've received many questions from trans folks, largely variations on "how did you do it?" I've realized that in order to be most helpful, my answer needs to extend beyond "my university happened to cover trans health care." When too few people are receiving coverage, trans individuals can hardly form an image of what to expect from the system. Insurance companies feed off a lack of transparency while reform strategies suffer from it.

To that end, the next posts in this series address the more unexpected elements of my health insurance experience. Let's start with my first major realization: An inclusive coverage policy is only the beginning. When I first learned that my insurance would pay for my top surgery, I thought the deal was sealed -- but I couldn't have been further from correct.

While I was privileged to start this journey with the therapy and hormone coverage that many medically transitioning folks are unnecessarily barred from, I faced two unanticipated limiting factors while preparing for surgery: (1) finding a surgeon willing to work with insurance, and (2) fitting the profile of a "properly" insurable trans person.

On the road to universal trans-inclusive health insurance, these two points need to be addressed -- and the earlier the better.

Takeaway #2: The System Can Incentivize Providers to Not Accept Insurance Upfront

Puttering around the Philadelphia Transgender Health Conference a mere day before I would receive my fateful insurance decision, I was stopped by a friendly voice behind me. I turned to spot a friend who'd recently heard that his job would be covering trans medical care (including therapy, hormones, and surgeries -- though not all procedures) the following year. When he caught up to me, his smiling eyes folded into an all-too-familiar furrowed brow.

"So, I just spoke with your surgeon. She won't accept insurance for my surgery," he said flatly.

Crestfallen, I bid him a quick goodbye and immediately tried to contact my surgeon; I had to understand what had gone awry for him. A tiny voice nagged me: Is it my fault she'd stopped accepting insurance for transgender patients? Had that last befuddled email, anxious phone call, or request for a slightly revised insurance letter been the straw that broke the camel's back?

When we finally connected, my surgeon diplomatically assured me that I wasn't to blame for her decision: Each of her five insurance cases a year was equally taxing on her reception staff, and, more to the point, the insurance company wouldn't pay her more than one fifth of her asking price. I nodded silently, unsurprised that the choice boiled down to money.

"I'll still help patients fill out reimbursement paperwork; a lot of other doctors won't even do that," she responded apologetically.

I was momentarily appeased, until I considered that my insurance company only accepts pre-approval. This Catch-22 rendered her compromise useless for those insured by plans unwilling to reimburse. Moreover, reimbursements have proved inadequate for the large number of patients who only receive back a fraction of the thousands they paid upfront.

In sum: There are still surgeons who accept insurance for transitional surgeries, but even among those, the ones who take insurance upfront face business pressure to no longer do so. It's less risky and arduous to accept payment first and have the patient be the only one waiting on whether or not their coverage will be approved.

Takeaway #3: Trans-Inclusive Providers Are Potentially Invaluable Allies

There's an argument to be made here for why trans-inclusive practices should accept pre-approval cases when they consciously know that they're caring for a structurally, historically low-income community. But I'll save that for another time.

Instead, let me center a bigger picture that I began to fill in that day, listening to the other side of my patient-doctor partnership: Both providers and trans patients feel unduly burdened by our current health care system. It's a nascent point of coalition.

Our goal is ultimately the same: improved quality of life for transgender people. We're recognizing that this is an important step toward demanding significant change from insurance companies together. Right now, however, our immediate fiscal needs -- an acceptable income for providers and affordable health care for trans patients -- can keep us at odds. And no matter how preposterous each side may seem to the other ("Surgeons demand such crazy prices!" "Patients have no idea about our overhead!"), our disconnect only guarantees rewards for one party: the insurance company.

It's time, then, to turn my focus to insurers' frameworks for understanding trans health care, which in turns informs their approach to trans-inclusive providers. Stayed tuned for Part 3.

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