How To Force Your Insurer To Cover Your Transition
A tutorial, partially from the Blue Bird Website
Insurance for trans people is… getting better. It still sucks. But with WPATH SoC8, the Affordable Care Act, and Bostock v. Clay County, the law is finally on our side. This is a brief guide for how to force American health insurers to cover your transition. Unfortunately, the US is where I live, and it’s all I know well.
And I’m gonna give you template documents to fight this fight too.
What You Need To Know First
There are caveats to this all, and things you need to know. Loopholes your asshole insurer can use to deny you coverage. You can probably find your insurer’s trans policies on this website, though not everything is listed there. Here’s what they are:
Is your insurance plan fully self-funded by your employer? Call your HR and find out—they’ll know offhand. If your insurance is fully self-funded, they can exclude whatever gender-affirming care they want. Your only hopes are to convince them to change or to get a different insurance plan.
Is the procedure you want done outside the United States? Most plans have boilerplate that categorically ban all planned healthcare provided outside the country, and that includes medically necessary care.
Do you live in a state like Florida, where public offices have been corrupted? The law is on your side, but unless you’re willing to run a lawsuit, corrupt officials can screw you, and get away with it.
If you’re clear on all of those…
How To Get Coverage For Any Gender-Affirming Procedure
WPATH Standards of Care 8 are the worldwide gold standard for describing what is and is not medically necessary care—and they say that basically everything is. The Affordable Care Act says that all non-self-funded insurance plans must cover all medically necessary care. Bostock v. Clay County says that trans people must be held to the same standards in every respect, by our employers, that cis people are.
In total, this means that US law says that anything WPATH SoC8 says is medically necessary is legally required to be covered by your insurer.
As you might guess, insurers don’t like this. So, here’s how you win the fight.
Find your surgeon/procedure provider and book a date for care (such as surgery).
Your claim will be rejected without a service date. You may have to put a down payment out of pocket for this, but remember: CareCredit exists.
Contact your insurer and ask for a Preauthorization Request Form. It’s usually one page. Follow the instructions on it. The Diagnosis Code is F64.0, F64.8, or F64.9. Any of them will work.
Contact your provider and get the following:
An itemized bill. This is crucial.
Their Tax ID Number and/or National Provider ID Number (if the preauthorization form asks for it).
The ICD-10 Procedure Code for your procedure. For instance, Breast Augmentation is 19325.
Contact your therapist and HRT doc and get letters saying you need this procedure as a treatment for gender dysphoria.
Download this template letter and replace all the yellow-highlighted bits with your information.
The letter is currently optimized for breast augmentation. If you use it for a different procedure, you will need to do some more extensive edits. Most of the sources of the bibliography, and all of the core arguments, apply to all gender-affirming procedures, however.
Submit your completed Preauthorization Form, your Letters, your Cover Letter from Step 5, a copy of WPATH Standards of Care 8, This Legal Bibliography if you’re fighting for FFS (If there are other similar ones for other procedures, send them my way and I’ll update these instructions), and your Itemized Bill to your insurer.
If your application is denied (it probably will be), appeal your denial. Most insurers deny covered procedures to see who will just accept their denial and go away. It’s illegal. They get away with it because there’s plausible deniability.
Your denial will come with an appeal form. It’ll be brief, just like the preauthorization form. Follow the instructions.
If you are denied again, appeal again.
You may have to repeat this step a few times. Be relentless. You have the legal right to coverage. They are in the wrong.
Eventually, after you exhaust all internal appeals at your insurer, by law, you can appeal to your state’s insurance regulator. They’re the people who will actually listen. And if/when they decide for you, their ruling overrules any decisions your insurer has made.
This all will take a lot of time. It’s entirely possible that it’ll still be going on after you’ve had your procedure and are recovering. Keep fighting. You asked for coverage before the procedure. They don’t get to run out the clock on you.
Disclaimers
I am not a lawyer. This is not official legal advice. I cannot guarantee success.
If you want legal advice, contact your the LGBT+ Rights lawyer at your state’s ACLU. They will help you. For free.
You may have to pay out of pocket or use care credit to make your procedure happen while you’re fighting.
Everything here relies on the state insurance regulator doing their jobs. I can’t guarantee that.
I love your blog overall, and have had this post pinned in a browser window since before comprehensive coverage took effect in my state, which fortunately happened before I got around to trying this process. However, I've now run into a remaining coverage gap, and wonder if this can still apply for that.
So, what prospect might there be to force coverage of fertility preservation? I reluctantly stopped estrogen a few weeks ago after one insurance agent thought it should be covered under Oregon HB2002, but now another agent is telling me it's definitely not, unless I can succeed on appeal with some argument of medical necessity. They seem to have covered my intake consult for it, but apparently won't cover the actual process. Sadly, I can't seem to find anything helpful in WPATH8, which only has recommendations about informing the patient and referrals for discussing options, and nothing about following through. Has anyone succeeded in this process for that? Do you know of any resources, or have any advice?
Looked into it. Indiana insurance doesn't have an official policy for exceptions (yet) for any surgery for what I can find. At least the plan I'm on.
In fact, a gender dysphoria diagnosis does mean I can get a breast augmentation and FFS covered.