+- FTM Surgery Support Forums (https://www.ftmsurgery.net/forums)
+-- Forum: FTM Surgery Support & Information (https://www.ftmsurgery.net/forums/f-ftm-surgery-support-information)
+--- Forum: FTM Top Surgery (https://www.ftmsurgery.net/forums/f-ftm-top-surgery)
+--- Thread: When Insurance doesn't cover (/t-when-insurance-doesn-t-cover)
When Insurance doesn't cover - taytayrooroo - 11-28-2015
Hi I'm Taymour, and I'm hoping to get top surgery with Dr. Crane or Satterwhite in San Francisco in the near future. After much deliberation we found out our Cigna plan we get from my mom's job doesn't cover it (She works for the county). It doesn't even cover my psychiatrist appts or meds!!
My understanding was that in California where I live, it is illegal to prohibit these surgeries from any insurance, or are specific plans exempt, like the Cigna one I have? And now that I know this, can I make an appeal? My mom has tried to call them but no answer and it has been a few weeks.
If I do pay out of pocket, what is the price for top surgery at Brownstein and Crane's practice? I can't get a good estimate online and would like to talk to someone who's had the surgery with them.
They want my insurance card and a fee of $150 to check the insurance which my parents don't understand why. I want to know if that's normal, or if I'm being ripped off. I saw somewhere that its part of the scheduling fee and that they work hard to get insurance companies to make them cover it, but can they really get it to cover the cost? We already know it won't cover, so is it worth it?
I'm sorry this is really long and a lot of questions I just feel so lost and I'm just so scared. Thanks for taking the time to read this. I trimmed it down to make it easier to read and took out info I found already on this website.
-Tay
RE: When Insurance doesn't cover - Joshua - 12-04-2015
Correct, in California it is illegal to deny medically required health care, including medically required transition-related care.
Quote:What will be covered? Who decides?
The DMHC Director’s Letter states that medically necessary transition-related surgery and other care must be covered by health care insurance sold in California. However, if a claim is denied, what constitutes medically necessary care for a particular individual will be determined through the independent medical review process.
The Independent Medical Review (IMR) involves 1-3 physician reviewers with relevant expertise in the area of medicine and who have no conflicts of interest. When an appeal is filed following the denial of coverage for treatment, the panel reviews the relevant scientific literature and generally accepted standards of care, the medical record of person in question, and what has been denied by health plan. Only then will they make a determination specific to that individual as to whether the care is medically necessary. If the IMR is decided favorably, the insurance plan must provide the needed service or treatment. To access the IMR process, call the DMHC helpline.
Source: FAQ - California’s Ban on Transgender Exclusions in Health Insurance
If denied, you can (and should) appeal. You can find links about the appeals process, as well as insurance requirements, here. There are also some phone numbers in the TLC FAQ above.
Brownstein & Crane charges in the area of $9000 for Top Surgery.
There's some work involved in getting an insurance pre-authorization and charging a fee for this is not uncommon. I know of guys who got only partial coverage and others who mostly had their surgery covered by insurance with B&C.
Before spending anything, check out those phone numbers I referenced. Those folks may be able to provide more specific guidance about next steps.
Don't give up!