Understanding insurance coverage can be confusing and frustrating for those seeking gender affirming care. There is no "best plan" for transgender care since each employer, school, or county has different plans and details. In California, some insurance plans are banned from excluding gender affirming care, while others are able to exclude such care.
Much of the information you need about your insurance can be obtained from the plan website, your employer's HR department, or the phone number listed on your card.
There are several aspects to insurance:
- Type of plan. An HMO is a plan where your primary care provider generally has to approve of you seeing any specialists. A PPO is a plan where you are able to make appointments with specialists in your network without needing approval from your primary care provider.
- Network. This determines what list of doctors you are able to see with full coverage. This can vary from plan to plan and also depending on the "level" of insurance. For example, a "gold" plan may have more doctors in the network than a "bronze" plan. If you want to see a doctor who is outside of your network, you may have to pay part or all of the cost out of pocket, or in some cases you may be able to get an out-of-network approval.
- Payer. Private/employer insurance differ in the way that the money is paid to the providers when they bill for services. Some insurance plans pay the fee directly ("fully funded plan"), while other plans involve your employer paying the cost ("self insured plan"). This is important to know in the case of filing an appeal for denial of services, since the two types of plans are regulated differently. For a "fully funded plan", the regulatory agency is the Department of Managed Health Care.
- Deductible. This is an amount that you are expected to pay out of pocket each year, before your insurance begins to pay for covered services. So, if you have a $1000 deductible, and you see a doctor and the bill is $450, and then there is a $600 lab charge, depending on the details of your plan, you might have to pay $1000 and then your insurance would begin coverage, and pay the final $50.
- Copay. This is an amount that you are expected to pay with each service (doctor's visit, lab fee, xray), regardless of the deductible. Sometimes this is a fixed amount (for example $30), and sometimes it is a percentage of the total fee (for example, 20%).
Medi-Cal (also known as Medicaid) is a state program for people who meet certain income requirements. While Medi-Cal is administered by the state, the specifics of your Medi-Cal plan are determined based on the county in which you live. Almost all Medi-Cal plans in California have an HMO model. Most gender affirming care is covered under Medi-Cal. For more information on Medi-Cal coverage and eligibility, please contact Medi-Cal at, or our office.
For residents of San Francisco, in order to receive most kinds of care at UCSF, you must be assigned to the UCSF Medical Group. San Francisco residents who are assigned to the Community Health Network (CHN) should seek care through the San Francisco Department of Public Health Transgender Health Services.
Medicare is a federal insurance program for senior citizens and for people with certain disabilities. Medicare can operate as an HMO or as a PPO. Medicare now authorizes coverage for gender affirming care.
Tricare is an insurance program for dependents in of people in the U.S. military. Please contact your insurance carrier or our office for more information.
PHARMACY BENEFITS
If your pharmacy has notified you or our office that a medication is not covered, but has not provided any information on covered alternatives, you must contact your insurance plan to determine what medications are covered. Often you can log into your insurance plan's website and there will be a section where you can find pharmacy benefit information. Use search tools to enter the general name of the medication (estradiol, testosterone, leuprolide, etc...) and search around to find which medications are on formulary. In some cases, there may be different "tiers" which represent different co-pays or cost shares for you. If your insurance does not cover the medication at all, you might find a coupon on GoodRx. In many cases, with the use of a coupon, paying cash for the medication can be similar in cost to the co-pay and cost shares associated with insurance coverage. Example screen shots are below.
