Wednesday, October 28, 2015

Looking at every plan for 2016 available to me at (I live in Shelby County, TN): Blanket exclusions for transgender health care


In the USA, it has long been the case that coverage for transgender health care has been specifically excluded, meaning indigent patients simply get nothing. There have been signs of a change in the past few years, with more and more employers adding coverage to their group plans, Medicare's exclusion of sex reassignment surgery being overturned, state regulators requiring coverage, and a proposed rule from the feds that may require coverage.

We've still got a long way to go, however, and for the past few years when it comes to coverage for sex reassignment surgery I've been on the outside looking in as none the plans I've been on have added coverage. Basically, the changes made so far do not seem to have reached me and blanket exclusions of transgender health care appear to remain common. It seems to still be common industry practice to exclude coverage of transgender health care.

There has been a lot of confusion, however, about the current status of coverage in this country. Some people think the feds have already outlawed these blanket exclusions, which is not true. Lots of people seem to think there is a "medical necessity" exception to these blanket exclusions, which is largely not true.

To rectify this confusion and to show the extent of the problem, I wanted to document all the health plans that are available to me for 2016 for these blanket exclusions of transgender health care on the exchange, to help determine how things are on the ground. I live in Shelby County, TN, so I will reference all the plans available to me. Open enrollment is not until November 1, but on plan previews for 2016 have already become available. I found 67 plans sold by a total of 4 health insurance companies, BlueCross BlueShield of Tennessee, Cigna Healthcare, Humana, and UnitedHealthcare. This is what I found.

BlueCross BlueShield of Tennessee

This is the coverage policy for gender reassignment:

Note this statement, which says gender reassignment may be excluded (all caps in original):
I was able to find the full policies for the BCBST plans:

On p. 72 of all policies except the Multi-state policies, this exclusion can be found under "V. Reconstructive Surgery" -> "2. Exclusions":
c. Surgeries and related services to change gender (transgender Surgery) [sic].
Interestingly, mental health care and hormones do not seem to be excluded, because of the way this policy is put under reconstructive surgery. I am currently on a BCBST plan and I've gotten psychotherapy and hormones covered even with the providers telling me they are billing GID/gender dysphoria.

On the Multi-state policies, the exact same exclusion can be found on p. 71 (which is specified). Here is a list of all plans, along with each plan's policy document:

 Bronze B07E, Network E (Bronze PPO) Plan ID: 14002TN0330049

 Bronze B02E, Network E (Bronze PPO) Plan ID: 14002TN0330044

 Bronze B07S, Network S (Bronze PPO) Plan ID: 14002TN0330051

 Bronze B02S, Network S (Bronze PPO) Plan ID: 14002TN0330041

 Bronze B04E, Network E (Bronze PPO) Plan ID: 14002TN0330045

 Bronze B01E, Network E (Bronze PPO) Plan ID: 14002TN0330043

 Bronze B04S, Network S (Bronze PPO) Plan ID: 14002TN0330042

 Silver S04E, Network E (Silver PPO) Plan ID: 14002TN0330013

 Bronze B01S, Network S (Bronze PPO) Plan ID: 14002TN0330040

 Silver S02E, Network E (Silver PPO) Plan ID: 14002TN0330012

 Silver S09E, Network E (Silver PPO) Plan ID: 14002TN0330016

 Silver S19E, Network E (Silver PPO) Plan ID: 14002TN0330031

 Silver S16E, Network E (Silver PPO) Plan ID: 14002TN0330020

 Bronze B04P, Network P, a Multi-State Plan (Bronze PPO) Plan ID: 14002TN0330034 (exclusion on p. 71)

 Silver S04S, Network S (Silver PPO) Plan ID: 14002TN0330003

 Silver S08E, Network E (Silver PPO) Plan ID: 14002TN0330015

 Silver S02S, Network S (Silver PPO) Plan ID: 14002TN0330002

 Silver S09S, Network S (Silver PPO) Plan ID: 14002TN0330006

 Silver S19S, Network S (Silver PPO) Plan ID: 14002TN0330033

 Silver S01E, Network E (Silver PPO) Plan ID: 14002TN0330011

 Silver S11E, Network E (Silver PPO) Plan ID: 14002TN0330017

 Silver S12E, Network E (Silver PPO) Plan ID: 14002TN0330018

 Silver S16S, Network S (Silver PPO) Plan ID: 14002TN0330010

 Silver S14E, Network E (Silver PPO) Plan ID: 14002TN0330019

 Silver S08S, Network S (Silver PPO) Plan ID: 14002TN0330005

Silver S09P, Network P, a Multi-State Plan (Silver PPO) Plan ID: 14002TN0330035 (exclusion on p. 71)

 Silver S01S, Network S (Silver PPO) Plan ID: 14002TN0330001

 Silver S11S, Network S (Silver PPO) Plan ID: 14002TN0330007

 Silver S12S, Network S (Silver PPO) Plan ID: 14002TN0330008

 Silver S14S, Network S (Silver PPO) Plan ID: 14002TN0330009

 Gold G10E, Network E (Gold PPO) Plan ID: 14002TN0330060

 Silver S11P, Network P, a Multi-State Plan (Silver PPO) Plan ID: 14002TN0330036 (exclusion on p. 71)

 Silver S12P, Network P, a Multi-State Plan (Silver PPO) Plan ID: 14002TN0330037 (exclusion on p.71)

 Gold G08E, Network E (Gold PPO) Plan ID: 14002TN0330059

 Gold G01E, Network E (Gold PPO) Plan ID: 14002TN0330057

 Gold G10S, Network S (Gold PPO) Plan ID: 14002TN0330055

 Gold G11E, Network E (Gold PPO) Plan ID: 14002TN0330061

 Gold G08S, Network S (Gold PPO) Plan ID: 14002TN0330054

 Gold G06E, Network E (Gold PPO) Plan ID: 14002TN0330058

 Gold G01S, Network S (Gold PPO) Plan ID: 14002TN0330052

 Gold G11S, Network S (Gold PPO) Plan ID: 14002TN0330056

 Gold G08P, Network P, a Multi-State Plan (Gold PPO) Plan ID: 14002TN0330038 (exclusion on p. 71)

 Gold G06S, Network S (Gold PPO) Plan ID: 14002TN0330053

 Platinum P01E, Network E (Platinum PPO) Plan ID: 14002TN0330070

 Platinum P02E, Network E (Platinum PPO) Plan ID: 14002TN0330071

 Gold G11P, Network P, a Multi-State Plan (Gold PPO) Plan ID: 14002TN0330039 (exclusion on p. 71)

 Platinum P03E, Network E (Platinum PPO) Plan ID: 14002TN0330072

 Platinum P01S, Network S (Platinum PPO) Plan ID: 14002TN0330067

 Platinum P02S, Network S (Platinum PPO) Plan ID: 14002TN0330068

 Platinum P03S, Network S (Platinum PPO) Plan ID: 14002TN0330069

Cigna Healthcare

Here is Cigna's coverage policy for gender reassignment surgery:|utmccn=%28referral%29|utmcmd=referral|utmcct=/&__utmv=-&__utmk=260421901

Naturally, this statement is found in the policy, informing the reader that there may be plans that exclude gender reassignment surgery:
For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document.
On p. 7 of the plan brochures, under "2016 PLAN EXCLUSIONS AND LIMITATIONS" (emphases in original):
Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex, including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.
This exclusion was found for all of the plans on the exchange. Here are all the plans and their plan brochures (with the exclusion on p. 7):

 Cigna Health Savings 6000 (Bronze PPO) Plan ID: 99248TN0020001

 Cigna Health Flex 6400 (Bronze PPO) Plan ID: 99248TN0020002

 Cigna Health Savings 2700 (Silver PPO) Plan ID: 99248TN0020003

 Cigna Health Flex 4000 (Silver PPO) Plan ID: 99248TN0020005

 Cigna Health Flex 2250 (Silver PPO) Plan ID: 99248TN0020004

 Cigna Health Flex 1200 (Gold PPO) Plan ID: 99248TN0020007


I could not find a coverage policy for Humana.

The exclusion is under "Limitations and exclusions (things that are not covered)" -> "Pregnancy and sexuality services" on p. 7 of the plan brochures:
Sex change services and sexual dysfunction.
Here are all the plans with the plan brochures:

 Humana Bronze 6450/Memphis PPOx (Bronze PPO) Plan ID: 82120TN0600022

 Humana Silver 3800/Memphis PPOx (Silver PPO) Plan ID: 82120TN0600023

 Humana Gold 2250/Memphis PPOx (Gold PPO) Plan ID: 82120TN0600024


Here is the coverage policy for gender dysphoria:

Again, this sort of statement appears, saying that transgender health care may be excluded:
In the event of a conflict, the enrollee's specific benefit document supersedes these guidelines.
I could not find the exclusion in the plan brochures, but on p. 12 of the plan brochures, it says that the list is not complete, directing the reader to this link, which contains sample medical policies for individual and family plans in each state:

I selected Tennessee:

I found the exclusion under "Section 2: Exclusions and Limitations" -> "M. Procedures and Treatments" on p. 31:
Sex transformation operations and other services.
It was not clear whether this Compass Plus Policy for Tennessee applied to 2015 or 2016, so I called UnitedHealthcare up. They said that the information about 2016 will be updated this Sunday, November 1, when next year's enrollment begins.

Here is the plan brochure which is used by all the plans:

Here is a list of all the plans sold by UnitedHealthcare on the exchange for me in Shelby County, TN:

 Bronze Compass 4200 (Bronze POS) Plan ID: 69443TN0070008

 Bronze Compass HSA 5200 (Bronze POS) Plan ID: 69443TN0070006 

 Bronze Compass 6400 (Bronze POS) Plan ID: 69443TN0070007

 Silver Compass 5000 (Silver POS) Plan ID: 69443TN0070005

 Silver Compass HSA 3600 (Silver POS) Plan ID: 69443TN0070004 

 Silver Compass 2000 (Silver POS) Plan ID: 69443TN0070003 

 Gold Compass HSA 1600 (Gold POS) Plan ID: 69443TN0070002 

 Gold Compass 1000 (Gold POS) Plan ID: 69443TN0070001 

I will update the information on UnitedHealthcare on Sunday. 

Update: Sunday came, and the same information was still there. It is currently there as of this edit.


As you can see, the market for individual health insurance on the exchange for Shelby County, Tennessee is not very friendly to trans people. All plans I could verify I have shown have blanket exclusions for transgender health care, at least for surgery, with no exception or qualification. There is no statement qualifying the exclusions that says "unless it is medically necessary" in any of these plans This is surprising in light of the companies, except Humana, being lauded for selling plans that cover transgender health care. Apparently, none of those plans are being sold in Shelby County, Tennessee, though I need to still verify the story for UnitedHealthcare. People reading about insurers providing coverage should keep in mind that such coverage decisions may not apply to any of the plans available to them.

Back in 2014, Medicare overturned its exclusion of sex reassignment surgery and it was said that private insurers and Medicaid take their cue from Medicare on what to cover:

Unfortunately, when it comes to the plans available on the exchange in Shelby County, TN for 2016, it seems they've not taken any such cue.

I wanted to document these blanket exclusions to show everybody that these exclusions remain the norm, and depending on which way UnitedHealthcare turns, they seem to be ubiquitous, with no plan avaialble that provides coverage. BCBST possibly covering psychotherapy and hormones is helpful, but it does not go nearly far enough. Some employers cover it and some states require coverage, but the effects of such decisions are limited in their extent, as this map shows for states requiring coverage:

I would like to see others document the exclusions in their health plans. I think if we have thorough documentation of this, we can make a difference with regulators such as HHS, who may or may not understand the full extent of these blanket exclusions. Documenting these facts should bring the full extent of these exclusions into view, showing that contrary to popular misconception insurers in most states remain free to make blanket exclusions on transgender health care, and they have largely NOT changed their practice.

If you want, you may document exclusions on your own blog or in the comments section of this blog post. I intend to send this post to HHS once I receive confirmation on UnitedHealthcare's policies, and I intend to share it with various LGBT and trans groups. Let's all do the same!

Update: I have used this to comment on the proposed regulation.

Friday, October 16, 2015

The true cost of denial

Today, I am on disability. A couple years ago, however, I was fairly productive, working at a job that paid low but was good and reasonably matched my skills. What happened? What happened is that something that people think will save money and not have any extra costs actually ended up costing everybody a lot.

I am a transgender woman who has been for most of my life very dysphoric regarding my male genitals. For me, sex reassignment surgery is a necessary solution. I worked at a decent job and the insurance at the job actually paid for my hormones, even though they were billed GID. I wanted to try to get surgery. This was something that had worried me for a long time, because I was not sure if I could ever get it. Some might say, Why don't you save for it? But my issues are that I am very poor when it comes to working over long time horizons and even simple organization. I knew that unless I made a hefty income, I would probably never be able to save for it. It would have to be made available to me, like it is to people in many other developed countries.

The summary plan description for my medical plan mentioned nary a word regarding sex reassignment They were paying for hormones, so I wondered: Would they pay for my surgery? I called them up and they said that nothing regarding transgender care was supposed to be covered, which I didn't buy because they covered the hormones under the diagnosis of GID. I had checked that with my endo's billing office and they confirmed that yup they were billing GID. I spoke to the corporate office, since this medical plan was self-funded, and they said what's on the summary plan description was supposed to be complete. Wanting to make sure, I spoke to a lawyer from a trans advocacy organization and he said yup they should cover surgery as long as it is medically necessary.

I found a surgeon to perform the surgery who was in network and then worked with my mental health professionals. I got surgery letters from both my psychiatrist and my psychologist. I also doubled-checked with my endo and he thought I was good to go, and also wrote me a letter. I submitted the letters and my insurance information to the surgeon's office in February, 2014. It would take a while before the info came back as there was a back log at the surgeon's office.

On April 24, 2014, I got the notice back that it was denied. This was very heavy for me and I began to feel incredible anger and despair. I started becoming unable to work and had to take leave. The lawyer helped me out more, but I eventually got the message that surgery was excluded, and they gave me the page from the Evidence of Coverage that said that. They had simply neglected to mention that on the summary plan description. My motivation was zero at this point. I would go on leave for good in August 2014. I applied for Social Security Disability and was awarded it. I also began receiving long-term disability for work. But before I could qualify for all these, I had to run up my credit card for my living expenses. I had to spend time in a mental hospital later that year.

Today, I am still on disability and have incredible resentment over the lack of access to surgery, not because I was unqualified but because I didn't have the money and no one else would pay for it. There is lingering anger that comes and goes, but for the most part I have become quite indifferent to life. Currently, I am in a state of anger which has motivated me to write this, but it will probably give way to indifference again at some point. Basically I am not working and I am receiving payments so I can live. My productive capacity was quashed and now quite a bit of money has to be paid to me. How much does that cost, all you out there who complain that sex reassignment surgery would cost too much to cover?