Vocabulary

Below are some key concepts to familiarize yourself with when navigating the insurance approval process for gender-affirming surgery. For an extended 101 guide on insurance basics, check out our Beginner’s guide to understanding health insurance.

When looking for a surgeon, it is important to determine if your preferred surgeon is in or out of network with your insurance. 

In network

• Agreements between your provider and insurance company
• Contracted physician
• You get “in-network” benefits if your surgeon has any of these:
  • Long-term contract with insurance company to cover all patients 
  • “Memorandum of Understanding” to cover patients for certain surgeries 
  • “Letter of Agreement” to cover just one patient for just one surgery

Out of network

• Agreements between your provider and insurance company
• You might not have “out of network” benefits (HMO’s usually don’t) because some plans force you to only go to ‘in-network’. However, some insurance plans allow you to see ‘out of network’ physicians
• If you do have out-of-network benefits: 
  • Any surgeon who accepts insurance can do your surgery and get paid by the insurance company 
  • The portion you pay (copay, coinsurance, and/or deductible) will likely be a lot higher

Copay

A predetermined flat dollar amount that you pay at the time of service for a covered service.
You typically do not need to meet your deductible before being subject to the copay amount.

For example, a patient may owe a $50 copayment for an office visit or medication while the insurance will pay for the remainder of the cost.

Coinsurance

After your deductible is met, this is the percentage of costs you will pay for covered services. On a high-deductible health plan, all covered services are subject to the deductible except for preventive care.

For example, a patient may owe 20% of the total cost of a surgery while their insurance covers 80% of it. Coinsurance usually will not apply until a subscriber’s deductible is met.

Deductibles 

The totals resolved ahead of the insurance providing payment toward care. For example, a patient may have a $250 deductible that needs to be resolved before a patient’s coinsurance applies. If the patient has a 20% co-insurance and the service was $500, the patient will owe the $250 to resolve the deductible plus 20% of the remaining $250.

Out-of-pocket maximum 

This amount is the most you will pay for covered services in a plan year. Once this maximum is met through the deductible, copayments, and coinsurance, your health plan pays 100% of the costs of covered services. This does not include your monthly premium/payroll contribution. For example, if the cost of care was $50,000 and the patient had an out-of-pocket max of $1,000, the patient would only pay $1,000 while the insurance covered the remainder.

Getting your surgery approved by insurance (aka “Preauthorization”)

What Is “getting approval” for surgery? Requirements for gender-affirming surgery approval:

• Have some type of insurance
• Have benefits included in your policy for surgery
• Letter of support (not always required by surgeons, but is required by most insurance companies)
• The surgeon’s written consult report (occurs after the surgery consultation visit)

Letter of support

Having a strong letter of support written by a medical professional stating a diagnosis of gender dysphoria is usually required for successful insurance approval. The letter should contain the following:

1. Diagnosis words: “gender dysphoria” 
2. Assessment words: “meets WPATH standards for mastectomy” 
3. Recommended words: “surgery is medically necessary”
4. Bonus: Information about receiving mental health therapy in the letter can be helpful
5. Bonus: getting additional letters (more than one) from different providers helps your case

If you are a Plume member and seeking a letter of support, we can help! Message the Care Team and let us know the following:

• Month/year you started gender-affirming hormone therapy (GAHT)
• Pronouns to use in letter
• Gender identity 
• Month/year you began identifying as your gender
• Month/year you began living as your identified gender
• Procedure(s) you are having 
• The date your letter is needed by

If your surgery denied by insurance

Sometimes, insurance companies may deny a request to cover gender-affirming surgery. What does denial mean, and what happens after that? 

• Initial denial is rarely a final answer
• Appeal the decision and file a grievance 
• Know your state law for insurance denials. You can contact a transgender support center or The Transgender Law Center for assistance

You have rights regarding the timing of a response. If your plan is “self-funded” and the policy excludes ‘gender-related’ or ‘transgender’ services, the situation might be more difficult.

How to appeal an insurance denial

If surgery is denied, you have the right to appeal within 120 days and to a third-party decision as part of the appeal process.

1. Prepare for your appeal
   1. Get lots of letters from as many providers as you can
2. Letters should be very clear about:
   1. Gender dysphoria, treatment recommendation, medically necessary
3. An appeal has a “reviewer” 
   1. Demand that your chosen reviewer is a member of WPATH (a physician who is truly informed and dedicated so that they can represent you well in the peer-to-peer process)
4. Be persistent, persistent, persistent 
   1. You may need to appeal to several layers higher within the company for further review

Other steps forward can include:

1. Recruit help from your HR department if your insurance is through your job
2. Search for local support groups in your state that understand state law
3. Contact the Transgender Law Center
4. Hire a lawyer

Additional resources

APLA Health – APLA Health offers one-time appointments for letters. They do their best to serve those in CA by covering Medi-Cal plans and having a sliding scale of $75 without insurance.

OutCare Health – OutCare Health provides navigation resources like being matched with gender-affirming providers of all specialties under your insurance plan.

Care Coordination at OutCare – Matthew, Care Coordination Director at OutCare Health, can provide more information on comprehensive case management and other services. Reach out at matthew@outcarehealth.org. 

Erin in the Morning – reporting on legislation that impacts transgender and queer communities.

Gender-affirming navigation – Keck Medicine of the University of Southern California can support referrals and care navigation for GAHT and gender-affirming gender. For more information, reach out at keckgendercare@med.usc.edu

World Professional Association for Transgender Health (WPATH) letter template – template WPATH recommends for your medical provider to use when writing a letter of support for gender-affirming surgery. 

Remember that you have the right to a provider and the right to treatment if your policy states that gender-affirming procedures are covered. For those interested in receiving a surgery letter of support, Plume can help by writing your letter! For current members, this is included in your membership and will require an appointment with your Plume provider to learn more information to write the letter. For non-members, Plume can support you by providing a one-time letter of support where you will have the opportunity to meet with one of our trans-affirming providers to gather the necessary information. Click here to learn more about how to receive a Letter of Support for gender-affirming surgery from Plume.