New Regulations on Health Care and what it could mean for us in the T community

Posted: July 30, 2010 in Changes, Discrimination, Dysphoria, GID, ICD-10, ICD-9, Insurance, medically necessary, pathologized, Transgender, update

The blog post from NCTEquality reads as follows:

“The Obama administration issued new regulations last week under the Patient Protection and Affordable Care Act which will protect consumers against abuses from health insurance companies. These new regulations will enable people to appeal decisions made by their health insurance companies and provide them with resources to do so. The regulations will go into effect on September 21, 2010.

Transgender individuals are often treated unfairly by health insurance companies. A health insurance company may deny a transgender person’s medically necessary treatment because of its transgender health exclusion or because it deems the treatment cosmetic or experimental. Additionally, an insurance company may refuse to provide coverage or drop coverage to someone simply because that person is transgender.

The new regulations will gives everyone, including transgender individuals, the right to appeal denials by health insurance companies. People can challenge 1) denials of medical treatments because an insurer deems it to be not covered by the health plan, 2) denials of medical treatments because an insurer deems them to be medically unnecessary or inappropriate for the individual, 3) the insurance companies decision to drop a person’s health coverage, and 4) pre-existing condition exclusions.  If an insurer refuses coverage of a service on the grounds that it falls within an exclusion clause in the plan (such as an exclusion for “cosmetic” or “experimental” procedures, or “services for sex transformation”), individuals may use this process to dispute whether the exclusion applies to that service.

Individuals must appeal through their health plan’s internal processes. According to the new rules, insurance companies must provide people with detailed information on the grounds for the denial of claims or coverage. Insurance companies must also provide notice of the right to appeal and how to do so. These notices must be done in a culturally and linguistically appropriate manner. There must be a full and fair review of the denial and an expedited appeals process for urgent cases.

Additionally, the new regulations gives individuals the right to an external appeal if their claims are not resolved through internal appeals. For the first time, these appeals will be reviewed by state or federal decision-makers who are independent from health insurance companies. This process is significant because almost half of individuals who elected an external appeal in states where independent reviewers exist  won their claim against their insurance company.

NCTE applauds the release of these new regulations. Individuals deserve to access medically appropriate healthcare without fearing that health insurance companies will arbitrarily deny them coverage or deny claims.”
For those of us that have been struggling with this for a while this could in fact be the one step in the right direction we have been waiting on since the moment a lot of use found out that insurance was even an avenue for physical transition assistance. Not only could this be a turning point but this could also mean that a lot more of us would be willing to take time to stand up to these companies who have tried their hardest to NOT pay for deemed medically necessary treatment. Which might I add any condition that is in the DSM is in fact a medically necessary condition that should be treated especially if there are DECADES of known cure.

Let me not just speak from a stand point of the on looker but as an American transman that has used this forbidden system of assistance to aid in his own transition. Not just saving me thousands of dollars but in fact saving me a life time of pain, distress, financial decline to the point other things around me are forced into debt, and the list goes on. The exclusions that have barred us from the medical care that we need has put this country in a seriously deep pit of debt. Don’t believe me?

“A 2001 study in five states found that medical debt contributed to 62% of all personal bankruptcies. Since then, health costs and the numbers of uninsured and underinsured have increased”

source-Health Care in the US

That was 9 almost 10 years ago, with the national avg. of unemployed sky rocketing what is your honest conclusion on what is happening with health care? People are pissed at our president for doing the right thing and what others have promised to do but somehow never managed to follow through on. We are about the only country in this world that does not have universal health insurance. For those that do not understand what or how that works let me just make it simple, you are born with coverage with no exclusions for medically necessary care and you die with coverage that bars no exclusions for medically necessary care. See anything wrong with the system here? In our southern most states you go an apply for medically care after the age of 21 and before 55 you will be told no. I can contest to this they told me and I quote, “in order to qualify you need to go get pregnant and have a kid, be mentally retarded, or clinically insane. your competent of everything were saying so you do not qualify”. So you mean to tell me a person already struggling that’s applying for medical care your advice is to bring another child into this world that can’t be cared for? States governing their own rules for mandated care is the reason we are running into these issues and exclusions and I’m not even going to get started on the issues that lay within private insurance companies. Not to mention half of the people working for the companies public and private DO NOT even know or understand their own set policies. This is why knowing your patient/client rights and advocating for self WILL get you a  longgggg way.

The fight for what is truthfully and deserving yours as a US citizen can be long, tiresome, and very stressful but the benefits you reap behind them are so bountiful. For those of you that have read my transition time line you can see the amount of surgical, hormonal, dr’s, labs, etc costs and they do add up.

Lets do a small one month break down shall we:

PCP Visit- $250

Therapist Visit- $200

Blood work- $300

T-Script- $125 (this price reflects for those who DO NOT know about low cost pharmacies, which is A LOT)

Month’s Total- $875

OK so we’re looking at $875 for just one month of medical care. Now for some people that’s no biggie BUT what about those of use that have no income, fixed income, or families to take care of that just will not allow us to spend that kind of money because there’s bills? So lets keep this $875 in mind that’s in the red now that’s gone unpaid, now taking away $125 because the vial(this doesn’t even include your needles) last a few months so we’re at $750. Now damn lets say your trying to get surgery and you have to see the Dr’s more then once that $750 now becomes $1500 on top of lets just say a $8000 trip to see a surgeon which now has you at $9500. How many of you with the above named exclusions can afford this? Mind you this is just 1 surgery out of many you may need, a lot of time people never factor in revision thinking it can’t happen to them. NEWFLASH your lying to yourself and you will be very pissed off if you don’t factor it in and it’s needed so this may add another lets say $1500 and that’s only IF the revision is free because you still have to get there. Which leaves you at now $11,000 of costs that are and should be deemed medically necessary and covered as such.

Let me show you from my surgical stand point just how much money I saved using insurance instead of paying out of pocket.

PCP visit: $250 + Labs and UA test for cancer $300=$550

Therapist visit: $400

2nd PCP visit to get ultrasounds: $250

2nd Therapist Visit: $400

Ultrasounds: $800 x2= $1600

3rd PCP visit for referral to hysto specialist: $250 + labs $300=550

3rd Therapist visit to get letter for hysto: $400

4th Therapist visit for Top surgery letter: $ 400

Specialist visit: $400

Pre op labs: $300

Hysto: $12,000

Post op check up: $400

4th PCP visit for referral to Top Surgeon: $250

Top surgery consult: $200

Pre op Labs for top surgery: $300

Pre op appt with top surgeon: $200

Top surgery: $10,500

Post top check up 1: $200

Post top check up 2: $200

Post top check up 3: $200

total: $29,700 COVERED BY INSURANCE (thats just for todays total i still have a lot of appts coming up)

Lets just say I wasn’t going to Miro, lower surgery would be covered too. For those that do not know a full metoitiodplasty state side can run you anywhere from 23K-35K that’s not including your travel, lodge, food, or post op care.

How many of you have that kind of money on hand? How many of you will ever have that amount of money on hand? Case in point insurance is a damn good thing to have and more of us need and deserve it now not when we are falling apart or going out of our minds from dysphoria. I was willing and able to sacrifice a few comforts to move around where I could get the insurance I needed. Some of us have the same ability but aren’t willing to sacrifice their comfort zones. Other of us don’t like being told no so there’s no will to test the system but myself and MANY others are sheer proof that if you test the system and know your rights you can get just what you need and save yourself the financial strains.

Hopefully with this new protection there will be more light shed and more people understanding or at least attempting to understand insurance policies, exclusions, and appeals to the point that a denial is the thing of the past and appeal is guaranteed coverage. Nothing comes easy in this life but if you have the will power to get what you need for your peace of mind then fight is what you must do. Think of every historic moment in time it took a fighting person to start a revolution so why not do the same for yourself and those that may follow behind you?

Knowledge is indeed power don’t let someone else’s ignorance and/or lack of facts discourage you. Know your laws, know your exclusions, know your policies, and know the system and it will take you farther then you expected. I once doubted myself and I will openly admit to that, but once I sat and got the facts in line and seen with my own eyes I am now post op. The time you spend wasting doubting the process could be the time you spend making sure the process is put into positive motion.

Food for thought…


  1. John says:

    I’m crap with this kind of stuff, so I was hoping you could dumb down this new policy for me a little bit. Does this mean that, after September, top surgery has to be at least partially funded by insurance companies? Or is it just saying that you have the ability to contest their decision and spend loads of time fighting them?

    Thanks for the help.

    • toyneboi says:

      It means when you can prove to them which 9 times out of 10 you can prove what your dealing with is medically necessary you have the right to appeal and it will now be a fair hearing. they now have to give you set details as to why you were denied and most reasons why people are denied are bull crap to the utmost degree. as I stated a lot of the people that work at the company do not even know what they are doing or their own regulations so they quickly deny based off bias opinions instead of real medical need. If you know your rights, laws, and policies you can better protect your self. Also knowing how codes work are very useful because a lot of people do not know the real medical terms for said “top” surgery or said “lower” surgery and when you don’t that can also cause a conflict where they have more grounds to deny you because then it rolls into the their exclusions. But with anything there is always a way to step around a no, no’s are mere roadblocks. Most people don’t have the drive to fight past that and thats what the insurance company is expecting.

      • John says:

        So this means, if you actually push for it, you have a much greater chance of getting the insurance to help out? Where before there was nothing keeping them from just out right denying you?

  2. John says:

    I suppose I should be more specific in my question. I’ve been looking into surgery and trying to figure out all of the financial whatnot. But, after looking around your blog, I’ve realized the much smarter way about this is trying to figure out how to get my insurance to pay for most, if not all, of the surgeries (top and hysto). So, my real question is, how do you get insurance to help you out? I’ve found a plastic surgeon who does top surgery and is covered by my insurance and I’ve found a few people who do hysto’s who are covered by my insurance (all of whom are located near me, thankfully). After that, what’s the next step?

    Thank-you for all your help. ~John

    • toyneboi says:

      well hell you have most of the work already done so your steps ahead….i’ll email you for more specific details as to how to get across that line. A lot of people have insurance plans that are easy to work with and they just are not sure as to how to do it.

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