How to Access Gender-Affirming Healthcare & Appeal Insurance Denials of Care (Health Insurance for LGBTQ Folks Ep. 6)

In the sixth episode of our Health Insurance for LGBTQ People series, we look at the process of getting access to gender-affirming care, discussing everything from filling out the marketplace application as a trans person to finding trans-affirming providers, getting prior authorization, and appealing denials of coverage.

Time stamps:

0:44: How to fill out the HealthCare.gov application as a trans person

2:26: How to find a trans-affirming doctor or surgeon

3:29: LGBTQ+ Healthcare Directory

4:23: How to get your insurance company to pay for your gender-affirming care

8:36: How to appeal denials of coverage for gender-affirming care

9:00: Submitting an internal appeal in writing

9:34: Sample internal appeal letter

9:55: Requesting an external appeal through your state's insurance commissioner

11:25: Taking legal action against your insurance company

Transcript:

Introduction

Welcome back to our series, Health Insurance for LGBTQ People. In our last episode, we looked through some policy contracts to figure out how to decide if a plan is going to cover gender affirming care or not. We looked at some exclusions, prior authorization requirements, and other criteria to help you find a plan that fits your budget and needs.

Now that you hopefully can find a plan that you like, in this episode, we're going to go through the rest of the process: how to fill out the application, enroll in that plan, find a doctor or surgeon, ensure your health insurance company will pay for your care, and how to appeal denials of coverage if your insurance initially denies it. Let's get into it.

The Marketplace Application Process

So, first we're going to discuss the marketplace application process. Now, I know that this isn't going to be a comfortable experience for a lot of trans folks. Unfortunately, until the application gets changed, this is just the process we have to go through if we want to be able to get access to health insurance.

Access to Pregnancy Benefits

The first two questions on the application will be your name and a gender marker. The only options for this are male and female. Now, keep in mind that if you're thinking about becoming pregnant or you are pregnant, you're going to want to put down female for the gender marker here so that you can be afforded the enhanced pregnancy benefits available through Medicaid if you apply for that.

What Name and Gender to Put on the Application

Other than that, the best thing to do here is to put down your legal name and the gender marker on file with the Social Security Administration to match your federal tax records. This is so that it matches with what you file for your federal taxes so that you can be afforded the correct amount of financial assistance through the advanced premium tax credit. If you put down a different name or if your gender marker doesn't match here, there might be some issues with making sure that you get the financial assistance that you're afforded.

So, please do go ahead and put down the information that the federal government has. And then keep in mind that after your application has been submitted and your financial assistance has been set up, you can go back in your account in healthcare.gov and change your name and gender marker in there. You can also make sure to change your information with your insurer and specifically with your doctor.

There is no reason that people should be calling you by your legal name if you've asked them to use a different name. It's just unfortunately you do need to put your legal information here on the form in order to get financial assistance.

Finding Providers: Primary Care and Gender Affirming Specialists

Next, once the application's filled out and you have access to your health insurance, you're going to want to get connected to a few doctors. First, you'll want a primary care physician, a PCP. And then second, you might also need a surgeon or a different provider for whatever gender affirming care you're hoping to receive.

Contact Your Insurer

There are a couple different ways that you can get connected to folks. The first would be through your insurance company. If you go on the website, they probably have a directory of all of the providers and doctors that are in network for your insurance. And that's a great place to start to make sure that you're going to get the maximum cost sharing benefits for whatever provider you have.

You can also call member services for your insurance company and ask them specifically for a doctor who covers gender affirming care or is versed in working with trans patients. And this is another good way that you can make sure to get connected to a provider who is going to be affirming and be able to help you with your gender affirming care needs.

Find a Provider through the LGBTQ Healthcare Directory

The second way to do it, something I recommend would be to look at the LGBTQ healthcare directory. This is a great resource that has a huge list of providers, including mental health specialists, hormone specialists, surgeons who have committed to being transaffirming providers. And you can go ahead and search here based on your location and hopefully find a provider who's in network for your insurance.

Ask Your Insurer about Gap Coverage

Now, if there isn't any provider in network for a specific procedure or surgery that you need done, it might be possible for you to work with your insurance company to get an out-of-network surgeon covered as in network as long as the insurance company agrees with you that there are no adequate in-network providers.

So, just keep that in mind if you have a specific procedure you're hoping to get done that you can work with your insurance company to try to get coverage for someone even if it's an out-of-state provider because there's no one closer to you.

Accessing Care and Getting Prior Authorization

Now, I want to talk about accessing care. Once you've found a doctor that you like and you're ready to move ahead with starting hormones or having a procedure done, there are a couple things that you may need to do. Hopefully, your doctor or surgeon will help you out with this. Hopefully, your insurance company will have something like a case manager who can help you along with this process as well.

Always Get Prior Authorization

But the most important thing that you need to do is to make sure that you have prior authorization for the procedure. We talked about this in the last episode when we were looking at policy contracts. There is generally a section specifically for what procedures and services require prior authorization. And it's really important to take a look at this and figure out if the procedure or surgery that you're having done requires prior authorization.

Now, what exactly is prior authorization? It's basically a process where you or your doctor will turn in some information about why the specific procedure or surgery that you're hoping to have done is medically necessary for you. As we saw with the clinical guidelines around some gender-affirming care procedures, there are specific requirements such as being on hormones for a specific amount of time or living full-time in your gender before you can get a specific procedure or surgery done.

These guidelines are generally based on medical standards, but in different states, different insurers might have different rules about what processes you need to go through before they'll cover a specific procedure for you. So once you've gone through this process, you and your doctor hand in the paperwork requesting prior authorization. The insurance company is going to look over everything and either approve or deny your request.

Do All Gender-Affirming Care Procedures Require Prior-Authorization?

Now, as you can imagine, prior authorization isn't required for most things. It's obviously not required for emergency services when there wouldn't be any time to get it. It's not required for routine procedures or preventive care that your insurance company has already approved you to get say once a year.

But in terms of gender affirming care, a lot of procedures and surgeries are still in this list of prior authorization requirements. It depends on insurer and procedure. So it's really important for you to check and make sure that your insurance company has agreed to pay their cost sharing portion for a surgery or procedure before you get it done.

Is Prior Authorization Necessary? (Yes!)

This definitely can be a time-consuming process, but it's really important to do ahead of time and to make sure you've saved yourself enough time before your surgery is scheduled because if you don't get prior authorization, it's possible that your insurance company won't cover anything at all.

Keep in mind, even if they would otherwise cover a specific procedure, if you don't get prior authorization, then they're probably not going to cover it. There is a little bit of text in basically every insurance policy that says if you are required to get prior authorization and you don't then they don't have to pay their portion.

Being Your Own Healthcare Advocate

So please please double check and make sure with your doctor, your surgeon that you have the prior authorization you need before your surgery is scheduled.

A thing that I like to do is to call the insurance company directly. You can call member services or billing and claims and ask them, "Hey, I'm having this procedure done. Do I need prior authorization for it? How much is it going to cost me?"

That's another important question to ask because you might not know what your cost-sharing portion is if it's a percentage co-insurance or if it's a flat fee because it's a co-pay. And you can go ahead and check out our previous episode on how to pay for health insurance if you have questions about those terms.

So, like I said, in most cases, your doctor or surgeon is going to help you with this process, filling out the paperwork, working with your insurance company, but I do just want to make sure that you are your own healthcare advocate and that you have asked these questions and gotten confirmation that:

• this procedure has been authorized,

• your health insurance has agreed to pay their cost sharing portion,

• you know whatever amount you're going to have to pay.

That way, you're not surprised by a bill down the line and you don't end up saddled with medical debts that you can't pay off.

What to Do if Your Insurance Denies Coverage

Another reason that it's good to get all this paperwork done in advance is because it might happen that unfortunately your health insurance company will initially deny your claim. This would be because they don't believe that a certain procedure is medically necessary because they think it's cosmetic or because they don't believe that you've gone through the proper process in order to be at the point ready to have this procedure.

Internal Appeals Process

Now, the first thing you need to know is that you can appeal this denial, but don't ask to appeal over the phone. If you call up member services and say, "Why did you deny this claim?" They're going to ask you if you want to file an appeal. And you do want to file an appeal, but you want to do it in writing.

The reason that you want to do it in writing is so that you can attach other information and documentation to support your claim. If you say yes over the phone, they're just going to hit submit and you won't get to add any more information to your appeal. So, you're going to want to appeal in writing.

There are a lot of great resources for writing an appeals letter. You can check out Advocates for Trans Equality, which has some sample letters and a lot of great documentation about medical literature and the standards of care. These are great resources to submit with your appeal to support your claim and say, “Yes, this procedure is medically necessary, and here's why.”

External Appeals Process

If your health insurance company still says no after that appeal, you then have the right to request something called an external review. This is where your claim gets sent to an independent body not affiliated with your health insurance company. They're going to review your request and then issue a final ruling. If they agree with you and say that yes, this procedure is medically necessary, then your insurance company is required to follow their guidance and pay for the procedure.

What you're going to want to do is find your state consumer guide on our website, where we have information about every state's insurance commissioners and the external appeals process. An external appeal would be conducted by an independent review board who would look over your case and the insurer’s denial and decide who's right and whether or not the insurance company needs to provide this coverage for you.

You can also file a complaint to the insurance commissioner directly. We have those links on our website, and you can get help from the insurance commissioner's office specifically to negotiate with the insurance company. Now, depending on what state you live in, you might be a little hesitant to do this. The insurance commissioner might not be sympathetic to our community.

However, do keep in mind that it is literally their job to support consumers who are facing difficulties with insurance companies and to make sure that insurers are not acting in bad faith and are following through on the obligations laid out in their contracts with consumers.

So, if your health insurance policy says that they should cover a specific procedure and they are telling you that they're not going to do it, go ahead and reach out to the insurance commissioner's office, get an external appeal, and work with the office to try to convince the insurance company to cover your claim.

Take Legal Action against the Insurance Company

Now, if you do all that and you still get a denial, there is one more step you could take, and this would be legal action against the insurance company. Again, this is a legally binding contract between you and the insurer, and if they're refusing to hold up their part of the bargain, you do have the right to sue. There are a number of legal aid organizations that help trans people with discrimination and denials of care. You can check out Lambda Legal, the Transgender Law Center, and Advocates for Trans Equality.

You can also research organizations directly in your state—maybe connect with your local equality organization—and they’ll have a good resource list for you so that they can fight on your behalf to get coverage for your gender-affirming care.

Other People to Contact

Now, if you faced a denial of care, there are a couple more things that I would like for you to do. The first is to reach out to us directly at info@out2enroll.org. You can contact us through our form on our website as well. We want to hear about denials of coverage because it helps us in recommending insurance companies to other trans folks in the future. It helps us to be aware of how insurance companies are acting, especially if it might not be in accordance with what's listed in their policy contract specifically.

The other thing to do would be to file a complaint with the Office of Civil Rights in the Department of Health and Human Services. Now, I know that the current administration is not going to be sympathetic to our community and in fact is working very hard against us to stop coverage of gender-affirming care. However, if you submit a complaint to them, it will create a paper trail so that hopefully in the future, another administration will be able to go back and look at these complaints and work with insurance companies to fix these issues.

And the same can be said for the marketplace specifically. Healthcare.gov also has a phone number that you can call if you're having issues of discrimination or denials of care. Again, this is just a good way to get your complaint documented so that a future administration can look into it and make sure that these insurance companies behave better in the future.

Recap

So, in this episode, we discussed the entire process of signing up for health insurance, finding a doctor or a surgeon, getting prior authorization for the gender-affirming care you need, and then dealing with denials of care and appealing with your insurance company to get the coverage that you deserve.

In our next episode, we're going to be talking more about your rights as a trans or LGBTQ person, both in terms of health insurance and healthcare providers.