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Hi, I'm Noah Lewis, and I'm going to share with you a roadmap for getting trans-related
health care — including surgery — covered
under insurance.
If you’re saving up for surgery, or
have given up hope of saving up for surgery, then
this video series is for you.
If you have surgery scheduled and are about
to spend $7,000 or maybe $30,000 out of pocket,
then you'll want to pay attention as well.
And if you’ve already paid out of pocket,
there’s a chance you might be able to get reimbursed.
I transitioned in 2005, when I was a student
at Harvard Law School.
I was the first openly trans student at Harvard Law, and I was unable to access surgery because
the student health plan had an explicit exclusion
for sex transformations.
So I investigated and wrote a paper on why
it was unlawful for Harvard to exclude transgender
health care.
I advocated with Harvard, and they eventually
removed the exclusions from both its student
and staff plans.
I know the dramatic difference that hormones
and surgery made in my life, and I know not
everyone has access to a law degree.
That is why I founded Transcend Legal.
Transcend Legal helps people access trans-related
health care under insurance.
Our goal is to eliminate all trans health
insurance exclusions in the United States.
When I was a law student, it was still quite
rare for companies and schools
to cover trans-related care.
But that is no longer the case.
Now is the best time in history for people
in the U.S. to access trans-related health
care through their insurance plan.
Trans people have been paying out of pocket
for health care for so long that many people
still assume that this is the best or only
way they will be able to get the hormones,
surgery or puberty suppression treatment that
they need.
This is particularly true if the surgery needed
is facial surgery or breast augmentation.
The fact of the matter is, if you have insurance,
there is likely the possibility that you could
have surgery and have it be paid for by your
insurance.
We believe that no one in the U.S. who has
insurance should have to pay for trans health
care out of pocket.
So that's our first take-home message.
Generally your insurance plan should cover
your surgery, and if it doesn't, there are
many legal protections available to help you
challenge that denial.
We'll be going over your rights and the
legal remedies available
later on in this video series.
Some people prefer to just pay out of pocket
rather than asserting their rights.
It can seem daunting to take on insurance
companies and fight for equitable coverage.
But you don't have to do it alone.
It's important to recognize that this is a
collective effort.
Trans people coming together as a community
and standing up to insurance companies is
the only thing that will bring about change
to ensure that all trans people of all income
levels can get the health care that they need.
So this isn't just about getting your surgery
covered.
It's also about getting your surgery covered
so that the next person doesn't have to have
that same fight.
We as trans people have all benefitted from
the trans people who came before us and were
open about who they were even in the face
of discrimination, violence, and great personal loss.
Those of us who have benefitted from our trans
forebears can draw on their strength to stand
up and fight for equal access to health care.
Trans people pay the same premiums and taxes
as everyone else, but receive unequal benefits
in return.
It's time for that to end.
So you're probably wondering, “How can I
know if my insurance plan will cover my surgery?”
This is not a simple question,
but we're going
to give you the tools you need to find that out.
So, a lot of people look at their insurance
card and they think, "Oh, I have Aetna" or
"I have Blue Cross," and they do a Google
search for "Aetna gender reassignment surgery"
and they find the medical policy for that
insurance company, and they think it's covered.
But that's not the whole story.
That's only the generic policy for how that
insurance company decides whether they are
going to cover a surgery for a given individual.
But what you need to know is what your specific
plan says about trans healthcare.
In order to do that, you need to get a hold
of your plan booklet.
This has a lot of different names - it might
be called a Certificate of Coverage, a Summary
Plan Description, a Member Handbook, a Benefits
Certificate, a Certificate of Insurance, and
so on.
So we're going to dive right in and give you
a homework assignment.
To get the most out of this video series,
you're going to need to find out what kind
of insurance plan you have.
To do that, you're going to need to get a
hold of your plan booklet.
This should have been given to you when you
first got the plan.
It may have been mailed to you, or if it's
an employer-based plan, given to you when
you started the job.
If you have a benefits or insurance website
that you can login to, you can start there.
Now you're going to see a lot of other documents
that are NOT your plan booklet.
You're going to see something called a Summary
of Benefits.
It's a little chart that lists things like
deductibles and copays for various types of
health care.
This is NOT your plan booklet.
What this document is useful for, however,
is seeing how much you will have to pay out-of-pocket.
We'll talk about that more later on, but let's
not be distracted in our quest for your plan
booklet.
Particularly if you're on an employer's website,
you might find a PDF that describes various
benefits that the company offers.
If you find a document like this, here are
some clues that it's probably NOT your plan
booklet:
First, if it has a lot of pictures of smiling
people throughout it, this is most likely
NOT your plan booklet.
No one is smiling when they read their plan
booklet.
Secondly, if it's describing other types of
benefits such as disability benefits, pre-paid
legal services or life insurance, it's less
likely to be your plan booklet.
Third, search for the exclusions and limitations section.
You may find language telling you that the
exclusions can be found elsewhere.
If you cannot find an exclusion or limitation
section, it is definitely NOT your plan booklet.
So if you're lucky, you'll be able to find
your actual plan booklet as a PDF.
It's a big document, generally 70 pages or
more.
And if you don't have an electronic copy,
you're looking for an actual paper booklet.
If you weren't able to find it online, you
can call the number on the back of your card
and ask them to send it to you.
Make sure you explain to them that you want
the big document that lists all of the exclusions,
not just the summary of benefits chart.
If you have a plan through your employer or
your parents' or partner's employer, you can
contact HR or the benefits department.
It's best to do this by email, and you should
ask for what’s known as the Summary Plan Description.
By law, most employers are required to provide
this document to you if you request it in writing.
If you already have your plan booklet, you’ll
want to immediately go to the exclusions and
limitations section and see if they have an
explicit exclusion for transgender-related
health care.
It might say something like “transsexual
surgery,” ”sex transformations" or "gender
reassignment surgery" or "sex change."
If you have a PDF you can search for the words
sex or gender and that will usually bring it up.
Occasionally you might be lucky and find that
there is explicit coverage listed for trans-related
care.
Sometimes only certain kinds of care are covered
and others excluded, and we’ll talk about
that more later.
If there is an explicit exclusion, that does
not necessarily mean you cannot get coverage.
There are many reasons why the exclusion might
not be valid.
For one thing, the plan booklet might simply
be out of date.
Insurance companies and employers don't always
keep their plans up to date.
Many plans removed their exclusions in January
of 2017 in response to nondiscrimination regulations
issued under the Affordable Care Act or Obamacare.
The second reason the exclusion might not be valid
is that your insurance plan might be regulated by one of
the many states whose insurance departments
have issued guidelines or regulations saying
that there cannot be categorical exclusions
for all trans-related care.
Note that if this is an employer-based plan,
the state where the insurance plan was issued
might be different from the state where you
live, and it's the state where the plan was
issued that governs - not the state where
you live.
The third reason why the exclusion might not
be valid is because your plan might not be
"insurance" at all.
If you have health care coverage through an
employer, it's going to be one of two things:
it's either going to be an insurance plan
or a self-funded health plan.
An insurance plan is where the employer buys
a group insurance plan from an insurance company.
The insurance company is responsible for paying
all of the claims and administering the plan.
In a self-funded plan, the employer sets aside
a big pool of money to which employees and
employers contribute and that money is used
to pay out the claims.
The confusing part is that the employer generally
hires an insurance company like Cigna or UnitedHealthcare
to administer the plan and that's the name
you're going to see on your insurance card.
In a self-funded plan, the employer is ultimately
responsible for the terms of the plan.
The way this works in practice, however, is
that insurance companies offer set plans to
employers, and generally, that's the source
of these explicit trans exclusions.
Many employers never sat down and decided
to exclude trans health care.
But the fact that your employer is responsible
for the exclusion means
you can ask them to remove it.
Many of you may be confused and wondering
how it can be the case that you can live in
a state such as NY that has an insurance bulletin
prohibiting exclusions, and work for a NY-based
employer, and yet, your employer has told
you there's an exclusion that they're not
getting rid of.
The reason for this is a federal law called
ERISA - the Employee Retirement Income Security Act.
That governs employer-based health plans.
If you work for a private employer and you
have a self-funded plan, ERISA overrides state law.
One thing ERISA does is allow large employers
that operate in multiple states to have one
employee health plan for all of its employees
regardless of what state they're in.
So, ERISA says that state insurance law and
state nondiscrimination laws don't apply if
it's a self-funded plan.
If your plan is insured, however, state insurance
law still applies.
The way to know which state’s law applies
is by looking at your plan booklet and seeing
what state the plan was issued in.
The remedies that are available to you if
there's an exclusion in your plan differ depending
on whether it's insured or self-funded.
So, you might be wondering, "how can I tell
if my plan is self-funded or insured?"
Sometimes it says so right in the plan booklet
that this is a self-funded, non-insured plan.
Easy.
Otherwise, it requires more detective work
and you definitely want to consult with an expert.
If it's a self-funded plan, it's required
to have a page that lists the plan administrator.
That page will provide information about if
the insurance company is just the claims administrator
or if they are acting as an insurer.
If it's an insurance plan, oftentimes there
will be a group policy number at the beginning
of the document.
You can also ask your benefits coordinator
which kind of plan it is.
So after you've completed those three steps
1) Getting a hold of your plan booklet
2) Looking for an explicit exclusion
3) Determining whether it's self-funded or
insured
you're well on your way to knowing what YOUR
health plan covers and what legal rights and
remedies are going to apply to your situation.
In our next video we're going to discuss how
to access care under your plan and what steps
to take if you are denied.
Thanks for watching and do us a favor, scroll
down, leave a comment.
Ask a question.
Let us know if this was helpful or not.
And please share this video with your friends
so that we as a community can move forward
and eliminate trans health exclusions.
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