Questions about insurance coverage and what to do to get it!

[Dawn D.]

Okay everyone, I need you input! I have a project I'm working on for a local Trans health council. We are looking at many issues concerning access to health care for trans people. My assignment is the insurance aspect of it. And, to the mod's, if this is in the wrong place, my apologies. Please relocate it if necessary.

So here's some of the questions I have:

1. Should there be coverage mandated to include gender identity treatments?

2. What levels of coverage if any, should be mandated?

3. What are the reasons that coverage is typically not included now?

4. What will be necessary for gender transition treatments to be covered?

5. If insurance co.'s eventually do cover or are mandated to cover gender transition treatments, should there be any waiting periods for coverage to begin?

6. If someone who is diagnosed with GID cannot afford an insurance plan that covers treatment options, should there be a mechanism available to make sure that individual is covered and treated in some way? If so, how?

7. Should an insurance co. have the right to refuse to cover GID related treatments?

8. If anyone can answer this, please do! How do larger corporations (like those with 100% ratings through HRC), successfully negotiate out exclusions of gender transition treatments so that they are covered in their health insurance plans?

9. Should whatever those mechanisms are, for negotiation, be made available and economically viable, to smaller group plans to help smaller business' become more diverse?


**10. This is to address Kates valid point about "medical necessity". I actually can't believe I didn't include it originally. Recently the American Medical Association drafted and approved Resolution No. 122, in which they do recognize TS issues as medically necessary and call for insurance companies to cover the treatments needed. Knowing this, should insurance companies be compelled by legislation in order to cover these procedures, if they will not do so voluntarily?


Well, that's probably enough for now. Please any and all thoughts are appreciated on each of these questions. However, in the interest of research, I would really like to avoid debate between us over these questions in this thread. We can open up other threads for that.


Thanks so much!


Dawn

[Katesback]

Hi there Dawn:

I paid every penny for all the surgery I have had. Do I think it should be covered? Well for a min I think it is better to focus on medical care that is provided through govt. programs like medicare.

I manage an HIV prevention program that targets the trans community. Many of the people I work with are not in a position to have a job with health care. Perhaps a better way to put it is most are working the streets to pay for transition. With that said I believe it is worth while for govt. plans to have provisions for at least hormones!!!!!!

Insurance companies? Well that is a good question. Pretend I am the CEO of an insurance company and I have a group asking my company to pay for services. My first responses would be to ask if these are medically nessessary?

Now from the same standpoint I think there is a case to be made currently that TS services are not medically nessessary from the CEOs standpoint.
The real issue is that TS needs to move from a disorder to a medical condition and from there arguments could be made that services are medically nessessary.

Katie

[Brooke Smith]

Of course if you always knew you where meant to have been born a girl,that would be a pre-existing condition...request for treatment denied.

Do you see where I'm going here? Under the current system you don't stand a chance. No one will ever give up anything until forced to. To do so would cut into the profit margin and what company would willingly do that. Insurance companies have complete staffs that their sole purpose is to delay and deny coverage. If they mess with you long enough, they hope you will just go away.

The only chance we have is government mandated health care. That doesn't seem to be going all that well at the moment.

[pamela_a]

The only chance we have is government mandated health care. That doesn't seem to be going all that well at the moment.

I disagree 100%. IMO the major reason things are so messed up is because the government has stuck their nose in it resulting in no competition. The government has destroyed everything it has touched when it comes to businesses and private sector with their mandates as well as the rules that limit competition.


To the OP and decisions which may be used as legal precident that treatment for GID is medically necessary I quote the following:
The U.S. Tax Court today issued a long-awaited decision in O'Donnabhain v. Commissioner of Internal Revenue, ruling that medical treatment for gender identity disorder (GID) qualifies as medical care under the Internal Revenue Code, and is therefore deductible.

First of all, NCTE applauds and thanks Rhiannon O'Donnabhain for her bravery and perseverance and to the Gay and Lesbian Advocates and Defenders (GLAD) for their smart and amazing work on this case.

Secondly, we are supporting GLAD in a community conference call GLAD is hosting tomorrow (Wednesday) February 3 at 6PM EST / 3PM PST. Attorneys who worked on the case will be on the call explain the case and its ramifications for transgender people.

Jennefer Atchison: If you are interested in hearing more about the case from the actual attorneys who worked on it, please join us for the call.

Toll Free Dial-In Number: 1-800-704-9804
Participant Code(s): 61898641#

Wednesday February 3
6:00 PM Eastern Time Zone
5:00 PM Central Time Zone
4:00 PM Mountain Time Zone
3:00 PM Pacific Time Zone
Please visit GLAD's website for more information about the case: www.glad.org

[Hope]

Okay everyone, I need you input! I have a project I'm working on for a local Trans health council. We are looking at many issues concerning access to health care for trans people. My assignment is the insurance aspect of it. And, to the mod's, if this is in the wrong place, my apologies. Please relocate it if necessary.

What a perfectly horrible task to be charged with. I wish you the best of luck and will help as much as I can.

1. Should there be coverage mandated to include gender identity treatments?

The answer a person will give (ethically) to this question will hinge on the answer to another question, specifically: "Is GID a choice, a fetish, or is it a medical condition?"

Because if we are just a bunch of "weirdoes" who think it would be neat to wear a dress - there is no way to argue that the larger community should be asked to support what would essentially be a hobby.

If on the other hand, we are people afflicted with a rather unpleasant and misunderstood mental / physical condition, then treatment should be made available just as it would (should) be for any other condition.

This of course, gets complicated. If you look around on this site, there are clearly some folks who refer to CDing as a hobby and / or fetish. Then there are those who quite clearly are afflicted with something more serious. So there are some of both, and I am not convinced that these are simply two ends of a continuum - I think there is a fundamental difference between the people who are happy being men who like to dress up (for whatever reason) and then there are the people who were born with male parts but fundamentally understand themselves differently.

But lets be clear - for those who understand themselves differently - this is not a choice. People do not commit suicide because they are prevented from taking part in a hobby. Science is showing us that there are differences in the brains of men and women and that those who are born with extra parts but understand themselves to be women have been found to have brains much more similar to female brains than male brains.

So... if this is not a choice, and it is a serious psychological / medical condition - why would it not be covered just like any other medical or psychological condition? There is no reason from an ethical standpoint. The only reasons are financial and political.

2. What levels of coverage if any, should be mandated?

Coverage should be provided at the same level as other conditions in a policy. My policy is currently an 80/20 split - (worthless if anything really bad happens - which makes it more or less worthless as insurance doesn't it?) I would expect that my insurer would be required to provide coverage at this same level, regardless of wether the claim was GID related or not.

3. What are the reasons that coverage is typically not included now?

Profit motive, and lack of political strength on the part of the transgender community.

If you ask a business man (or one of his stock holders) wether he would rather pay for your SRS, or buy himself a new boat, he will pick the boat every time.

Health insurers are not our friends, and they are not interested in our health, they are corporations and as such, they have a fiduciary responsibility to make as much money as possible. And that is all they care about. Anything else they tell you is white-wash.

If the transgender community had the political power necessary to influence legislators to draft laws requiring health insures to cover transgender related issues - they would grudgingly do it. But we don't, and so they won't - because boats are more fun than care for someone you don't know and will never meet.

4. What will be necessary for gender transition treatments to be covered?

Remove the profit motive from healthcare decisions.

The only entity that is capable (or interested) in operating an enterprise of the scope of health insurance without a profit motive is the government, and that means "socialized healthcare;" and the party of No has made it clear that they will do everything in their power to prevent the healthcare system that provides better care at lower cost to the rest of the western world from being implemented here.

So perhaps another answer would be to get people to stop voting for the party of No?

Another option would be to exercise the political clout necessary to influence legislators to draft laws requiring health insures to cover transgender related issues ... but I think it is safe to say that is not going to happen in my life time, certainly not in the next 20 years. We don't have that kind of clout, and the insurance industry has the clout to oppose it.

5. If insurance co.'s eventually do cover or are mandated to cover gender transition treatments, should there be any waiting periods for coverage to begin?

Healthcare decisions should be made by patients and doctors. The only "waiting period" involved should be related to the then current standards of care.

I'm not really sure I understand the question. If the question is "Should people be refused benefits because they have not yet paid sufficient premiums?" Then that is a misunderstanding of the way insurance works, and the answer is no. Though this is a common excuse given by insurers to deny claims. The sole purpose of insurance of any kind is to distribute risk among a larger pool of people. When that risk occurs in the policy period is irrelevant. If the question is "should a person without insurance be able to take out a policy after they are diagnosed with a problem?" then what we are really talking about are pre-existing conditions, and that is a completely different set of problems.

6. If someone who is diagnosed with GID cannot afford an insurance plan that covers treatment options, should there be a mechanism available to make sure that individual is covered and treated in some way? If so, how?

Of course.

Ethically, it is unspeakably foul to deny care based on a person's ability to pay.

Again, the solution is "socialized healthcare." Everyone is covered, and care is available, and affordable when needed.

7. Should an insurance co. have the right to refuse to cover GID related treatments?

In theory yes, to the extent that an insurance company should have the right to refuse any medically necessary treatment. Which is to say - no.

From a purely business perspective - sure insurance companies should be allowed to do whatever they want, to cover what they want and to not cover what they don't want, to drop coverage for sick people and to refuse to cover people who have chronic illness - but that theory is more than a little ethically troubling. And unfortunately the "free market" theory does not work in the case of health insurance.

The economic theory that we operate under is that if one company refuses to cover XYZ procedure, then their insurance will be seen as less valuable, and so customers will choose to buy policies from another company. This is a very nice theory, and in some other situations, works - very well.

Unfortunately this does not work in reference to health insurance, because of a few issues:

First, most people who have insurance available to them, do not get to choose what sort of policy they will have - those decisions are largely made by one's employer - so even if there were an affordable policy that covered GID I would not be able to buy it - at least not through my employer - and as we all know - if you don't get health care through your employer - you are going to pay more and get much much less.

Second, no insurer is likely going to cover gender issues because to do so, or failing to do so will not win them, or loose them a significant enough number of customers for them to notice - certainly not enough to off-set the cost of care for those who "get lucky" and need the coverage they paid for.

Third, people don't buy insurance thinking they are going to need it. No one says "I better buy insurance because I am going to get cancer at 45, or be in a freak accident in a year." Even those who buy insurance thinking that they MIGHT need it at some point down the road - NEVER in a million years think "I might realize that I am really a woman - so I should get the policy that includes coverage for GID - because that is the more valuable policy." If people saw GID on a menu of options - they would think "I might get ALS, but not GID..." For one thing - GID is something that starts in the womb... If you think you might need the coverage, you have a pretty good idea already - and that gets back to pre-existing conditions. So adding coverage for GID to a policy provides no value to buyers, but does open the insurer to greater liability. That just isn't going to happen.

8. If anyone can answer this, please do! How do larger corporations (like those with 100% ratings through HRC), successfully negotiate out exclusions of gender transition treatments so that they are covered in their health insurance plans?

That is easy. Google (I assume) says to BCBS "Hey, we aren't Walmart. We value our employees, and we want them to be healthy and happy. You should see the gym we built for them. Anyway - hey, we were wondering, would you be interested in selling us 12,000 health insurance policies today? You would? That is awesome! Remember when we said we care about our employees welfare? Here is what we need you to cover.... Oh - you don't want to cover GID... that's cool, we understand, have a good afternoon. Hey there Aetna, we are Google and we are in the market for health insurance for our awesome employees, and we were wondering... would you be interested in selling 12,000.... Wait hang on one sec, it's my other line... What is that BCBS? You DO want to cover GID! Great! Lets do some paperwork!"

9. Should whatever those mechanisms are, for negotiation, be made available and economically viable, to smaller group plans to help smaller business' become more diverse?

Of course they SHOULD - but they won't - and frankly - there is no way for it to happen. It isn't that it costs any more for an insurer to cover someone who works for a small business than it does for them to cover someone from XYZ corp... it's just that someone buying 5 units doesn't have the clout in the market place that a person who is buying 12,000 units has. The insurer can (and does) squeeze the person buying 5 units, where the person who is buying 12,000 units is bringing so much more money to the table that they are a much more desirable customer. There is no way to change that within the current market system.

One way to fix this would be to decouple insurance from employment - but all that does is take away the big players - then the insures can squeeze all of us - because we are all buying 1, or 2, or 5 units and no one is buying 12,000 units any more.

Another fix, a better fix of course is to remove the profit motive from health insurers... but that leads to (in scary booming voice) SOCIALISM!!!!

**10. This is to address Kates valid point about "medical necessity". I actually can't believe I didn't include it originally. Recently the American Medical Association drafted and approved Resolution No. 122, in which they do recognize TS issues as medically necessary and call for insurance companies to cover the treatments needed. Knowing this, should insurance companies be compelled by legislation in order to cover these procedures, if they will not do so voluntarily?

Of course they should. Medical decisions should be made by doctors and patients, not health insurers. But we all know that insures won't make this decision voluntarily, and we know that our legislators won't compel them to do it...

I do really feel bad for you being asked to tackle these issues. There are easy, obvious solutions - but we as a nation lack the political will for some reason to enact them. That has to be the definition of frustration. Perhaps the best thing that can happen is that things get so bad in the next few years that even the NOP has to get on board with health reform... just hope you don't have a serious need for healthcare before then?

[Dawn D.]

What a perfectly horrible task to be charged with. I wish you the best of luck and will help as much as I can.

Lol, Hope, it would be more accurate to say that I may be a little masochistic. I actually volunteered for this issue. I've always like to be challenged. Thanks though, so much for your answers! I do appreciate them.

To all that have answered thus far, Thanks very, very much for your thoughts! They are all quite helpful! Very good answers! I'd love to hear more thoughts on this topic as well from anybody else!


Dawn

[SuzanneBender]

The real issue is that TS needs to move from a disorder to a medical condition and from there arguments could be made that services are medically nessessary.

Katie

Right on Katie. For those of us that need medical treatment it is a issue of our bodies not matching our minds, brains or souls not the other way around.

[Melissa A.]

I disagree 100%. IMO the major reason things are so messed up is because the government has stuck their nose in it resulting in no competition. The government has destroyed everything it has touched when it comes to businesses and private sector with their mandates as well as the rules that limit competition

Really? So, unlimited, unfettered capitalism, without any regulations would make my insurance company stop denying my claims(and some any coverage at all) due to any preexisting condition? It would make them change their view that healthcare is a commodity? Insurance companies would stop giving bonuses to managers who's departments deny the most claims? Are you saying I wouldnt have to fight my mental health provider tooth and nail for every claim, even though I was with the same therapist for 2 years? They do all these things because the mean ol' government already makes them do it? Even without a healthcare reform law, that as presently made up, would hand them 30 million new customers without forcing them to change anything else of consequence? But things will still suck because the government has detroyed health care, forcing innocent insurance companies who just want me to be healthy, to be so mean and callous against their will?
I had no idea. Thank you, thank you for this moment of enlightenment.

Hugs,

Melissa

[Melissa A.]

1.Should there be coverage mandated to include gender identity treatments?

When we talk about Gender Identity treatments, we're talking about a wide spectrum of people, albeit a small amount of people, consumer-wise. Should treatment for transition be covered? The AMA and the APA seem to think so. But they don't decide what gets covered. Right now, even if health care reform becomes a reality, I fear any talk of covering treatment for transition will result in the ususal hysteria from opponents. Frankly, I would prefer we stay way under the radar, in the current political climate. I quietly had most of my therapist visits covered over the last couple of years, and I didnt even have to claim depression. We honestly admitted I have GID. Same goes for my meds. they are all covered, for now. But I watch the news and read all the truly disgusting misinformation spewed out there by those who clearly know better, and that is being swallowed by those who find it easier to believe them than to think for themselves, and I feel like I'm hanging on by a thread, just one O'Lielly commentary away from being "found out". And I am one of the lucky ones, with pretty good insurance. Most don't have to worry about being found out. They don't recieve squat for their premium dollar.

2.What levels of coverage if any, should be mandated?

Again, Mandating anything in this climate will be difficult. My view is if transsexualism is a physical birth defect, and transition is the only treatment that is proven to work.(That isn't totally true yet, but it's the only treatment with any track record of success, by a long shot) then.....yeah, everything should be covered, within reason. GRS? A given, to me. HRT? Well, duh. FFS? a little more subjective, but yeah, definitely covers life quality issues. When you start talking about Breast augmentation, when hormones are available to get you there to a certain point, for most, then you are getting into a much more subjective area of disscussion.

3.What are the reasons that coverage is typically not included now?

Money. Profit. A System that isn't consumer-friendly, in any way. The Free Marketers keep telling us their vision, set free, will solve everything. Even in my wildest, most utopian fantasies, I really can't see that happening. Somehow, health care IS different from other things we buy. I don't know how some find it so hard to put aside their ideology and see that for a moment.

4.What will be necessary for gender transition treatments to be covered?

Public presure and a little bit of fairness. Honestly I can't see that happeneing, except in some cases, where large companies use their clout to make it happen, under our current employer-based system.

5.If insurance co.'s eventually do cover or are mandated to cover gender transition treatments, should there be any waiting periods for coverage to begin?

If something is covered, it's covered.If you are talking about the current waiting period to recieve hormones while you talk to a therapist for a couple of months(a very loosely-enforced protocol, anyway), yeah, I don't have a huge problem with that, even though on a base level I find it a little intrusive. Anything else should be like any other approved medical procedure.

6.If someone who is diagnosed with GID cannot afford an insurance plan that covers treatment options, should there be a mechanism available to make sure that individual is covered and treated in some way? If so, how?

Yes.

7.Should an insurance co. have the right to refuse to cover GID related treatments?

Right now, they do have that right. It all depend on how you define GID and where you classify it. Do I think they ought to cover it? What do you think?

8.If anyone can answer this, please do! How do larger corporations (like those with 100% ratings through HRC), successfully negotiate out exclusions of gender transition treatments so that they are covered in their health insurance plans?

As Hope explained, Clout, money and leverage. How we get there is obvious to me, though some obviously dissagree.

9. Should whatever those mechanisms are, for negotiation, be made available and economically viable, to smaller group plans to help smaller business' become more diverse?

Again, I hate to parrot someone else, but you wanted us to answer-Ain't possible, the way you word it.

10.This is to address Kates valid point about "medical necessity". I actually can't believe I didn't include it originally. Recently the American Medical Association drafted and approved Resolution No. 122, in which they do recognize TS issues as medically necessary and call for insurance companies to cover the treatments needed. Knowing this, should insurance companies be compelled by legislation in order to cover these procedures, if they will not do so voluntarily?

Absolutely. Don't hold your breath.

Good luck, Dawn. I truly hope your project makes a difference in the lives of some. If not sooner, then hopefully Sometime. And I apologise for my previous post, in defiance of your request. I really do.

Hugs,

Melissa