TfTM Blog: My Insurance Requirements for Top Surgery by MK

Contributor: MK

Top surgery is covered by my health insurance! Time to pop the champagne?

Insurance companies covering trans*-related surgeries isn’t yet common for most employers and universities. Mine happens to cover, presenting me with what at first appears to be a “jackpot!”, followed by the realization that there’s a long rainbow to walk over to get to the gold.

Even a glance tells me that the requirements insurance companies place on us are much stricter than if you were paying out-of-pocket. As this account points out, many top surgeons require a letter from a therapist or doctor stating that surgery is the next step in your transition. Some surgeons do not even require a letter from a doctor, and instead ask for your informed consent. Insurance companies will likely require lengthier letters from all your clinicians, a letter from your prospective surgeon, and a requirement for a length of time you have expressed gender dysphoria to your clinicians (whether or not you acted upon it).

As listed in my Summary of Benefits 

But my policy states that “Gender Reassignment Surgeries” are covered!

Important: your insurance company simply listing in their Summary of Benefits (a.k.a. “Evidence of Coverage”) that they cover Gender Reassignment Surgeries is not enough — you will need to get approval from them. Their requirements for approval can be sent to you separately if you request them over the phone. Not meeting any requirement is grounds for them rejecting your claim for coverage.

If you get pre-approval and you’re working with a surgeon who will accept insurance up front as a form of payment, you’ve got it made. If you cannot locate such a surgeon, you will have to decide whether you are able to pay the surgery costs up front and then submit your own claim to be reimbursed.

A separate document lists out requirements for coverage in detail

Wait, wait…. A separate list of pre-requisites to get approved for top surgery? I’m trans* already, what more do they want?

Okay, so most of us aren’t so naive as to think there won’t be yellow tape to slash through to get what’s ours. As an example below, I’ve rephrased the requirements of my insurance company in my own words.

I’d like to stress that these are the requirements for my insurance company only, and they do vary among companies who cover what are commonly listed as “Gender Reassignment Surgeries.” 

And hey, if you’re a trans* woman reading this, it all applies to you too! I tend to write “guys” or “male” or “testosterone” because this is how I read the policy to myself, but this would definitely be useful information for women as well.

EXAMPLE OF INSURANCE REQUIREMENTS FOR TOP SURGERY

Diagnosis
1) Must be a legal adult (18+).

2) Must have a diagnosis of “Gender Identity Disorder” (also listed as “Gender Dysphoria”) from either a therapist or doctor.

Hormones
3) Must be on testosterone for 1 year continuously, UNLESS you are an FTM seeking TOP surgery only. You can have the hormone requirement waived as long as your doctor(s) can attest you have met every other requirement.

Note: Going off testosterone at any time during this year can disqualify you for coverage, as it indicates to the insurance company that you are not fully committed to your transition.

4) If you are taking hormones, they must be (a) recommended by a therapist, (b) given to you under the supervision of a doctor, and c) used only as directed by your doctor.

Presentation
5) Must be living full-time as male continuously for 1 year, in all aspects of daily public life — work, volunteer work, and school included. (Referred to as the “real-life experience” by many providers).

If you have not yet lived 1 year as male, this requirement can be waived if your doctor indicates in their letter why they don’t think it clinically necessary that you be living as male for a full year prior to surgery.

Letters
6) 6) You must provide at least 1 letter from a clinician. This must be a therapist with a doctoral degree (PhD, MD, PsyD, etc.) who is capable of establishing whether you have any “other” mental illnesses. You must have been seeing this therapist for at least 1.5 years.

OR

A second, third, fourth, etc. letter can be written from another therapist or doctor, or a joint letter from all of your doctors (with at least one co-signer being a PhD or PsyD in psychiatry/psychology). The letter(s) must add up to 1.5 years of treatment by doctors aware of your gender dysphoria/desire for surgery. It does not have to be trans-specific treatment (i.e. gender therapy); for instance, one clinician can be your family doctor or primary care doctor who documented your dysphoria/desire for surgery long before you acted upon it.

Only one of the letters has to go into the following details, with the others stating simply how long you have been in treatment and what kind of treatment, and an agreement with the first letter. The primary letter must answer:

 1) Is the doctor on a Gender Identity Disorder treatment team or in private practice?

          2) How long has the clinician has been treating you?

3) What type of treatment does the clinician provide (e.g. psychotherapy, primary care, etc.)?

          4) What are general identifying characteristics of the patient?

          5) How long the patient has been in therapy specifically?

          6) What are the psychological aspects of your Gender Identity Disorder?

7) What are your other diagnoses, if any? (2 diagnoses together are referred to as “co-morbid” conditions).

8) Have you completed the specific eligibility requirements of the insurance company? 1 year on testosterone, 1 year living full-time as male. Or an explanation why these requirements should be waived (as explained above).

9) How well have you followed your doctor’s treatment plan? What is the likelihood you would continue to comply?

10) Have  you made significant progress towards consolidating your male gender identity at work, school, in relationships, and with any other mental health issues you may have?

 11) During the 1+ year living as male, have other people besides your clinicians been aware you are male and could attest to your ability to function as male?

          12) Are you in the process of acquiring a legal, gender-appropriate name?

7) You must provide 1 letter from a surgeon. This letter must:

1) Repeat that you have met all of the eligibility requirements of this policy. 1 year on hormones (unless waived, see part 6.7 above). 1 year living full-time as male (unless waived, see 6.7), with no “returning” to female gender identity. 1.5 years in treatment for Gender Identity Disorder total.

          2) Name the surgery and that you are likely to benefit from it.

          3) State that they have personally communicated with your therapist.

4) Acknowledge that they have told you the consequences of your surgery. This includes how long the hospital stay is, any possible complications, and rehab requirements.

Woah, that’s a lot of footwork…

More to come on my track record in the insurance hurdle-jumping event.

Does that look like a mustache to anyone else?