The Longest Mile: Gender Affirming Surgery and Health Insurance –

The last mile is usually the hardest. For members of the transgender community, it can also be the longest mile in a long journey. Almost all California health plans (Medi-Cal, individual & family, small group, and many large employer groups) must cover transgender health care services. This includes gender affirming surgery.

Gender Affirming Surgery With Your Health Insurance

While most California health plans will cover gender affirming services and surgery, it is not a straight line. It can be a maze of appointments, letters of diagnosis, prior authorizations, and finding the right people in your health plan’s network of doctors and providers. For a perspective on this daunting journey Julie (MTF) helped educate me on the process. Below, I share Julie’s thoughts and perspective on the journey for gender affirming surgery.

What are the steps necessary to be considered a candidate for gender confirming surgery?

Talk to your Doctor

The first stop after deciding that you desire gender affirming medical services is with an in-network Primary Care Physician (PCP.)  Your PCP can support you in getting the referrals that you’ll need to move forward for example, with hormones, therapists, hair removal specialists and a surgeon.  It can be helpful to find out if your PCP has experience and/or training working with transgender people and if they are willing to help you with your process.  PCPs without experience working with transfolk or who may refuse to be supportive for religious or moral beliefs can slow your process, which can be traumatic and necessitate reporting. 

On the other hand, a PCP who is an ally from the beginning can help you more easily and smoothly navigate your journey in a timely fashion.  Kaiser of Oakland and San Francisco both have clinics that specialize in transgender services.  You can speak with a member services representative and ask for PCPs who have experience with transgender folk and ask them to be assigned to you.

Medically Necessary

To move forward with gender affirming surgery and treatment you will first need a diagnosis of gender dysphoria that necessitates certain health care services.  It is this diagnosis, and the mitigation thereof, that is the key that opens doors for a trans person medically.  PCPs and the other medical care providers will have criteria that you will need to meet along the way and those standards are outlined in a document known as Clinical UM (utilization management) Guidelines.  Understanding the UM Guidelines for gender affirming surgery is both helpful and important when navigating toward surgery and getting favorable results as you and your insurance carrier interpret claim decisions.

Hormones

Getting on a hormone regimen to align with your gender identity is a large part of the gender affirming process.  Hormones may be prescribed initially by your PCP and/or by consultation of a therapist and possibly an endocrinologist.  There may be a minimum amount of time that you are required to take hormones such as 12 months.  However, in some cases, the time required might vary.

Two different therapists

When it comes to therapists, there are two different types that are required to be seen and you’ll need a letter from each that states that you have met the requirements to receive surgery.  One therapist needs to be of PhD level and both letters must be dated within 12 months of surgery.   Therapists in your health plan may not have experience writing letters for gender affirming surgery or be able to provide you with a PhD level practitioner for the same.  In that case, having done your homework and having a therapist that your PCP can refer you to that is knowledgeable and you’d like to work with is key. 

Even when you have a transgender ally as a therapist, know that you’ll serve your process best by knowing what will need to go into your letters. Be prepared to share your transgender history with your therapists quickly, easily, and thoroughly enough so that they can help move you forward.  Having a copy of the aforementioned UM guidelines to share with your PCP and therapists will be helpful all around. 

Bottom surgery hair removal is facilitated by a letter from your surgeon stating that such hair removal is medically necessary.  Likewise, you may also be able to pursue facial hair removal as medically necessary with letters from your PCP and/or therapists due to gender dysphoria.  Some networks are stricter on their policies for facial hair removal but there are others, for example Kaiser in Oakland & San Francisco through their transgender clinics, who will more easily fast track you through their system for facial hair removal too. (The issue is if the health plan categorizes the procedure as medically necessary or cosmetic. Cosmetic procedures are generally not covered.)

To prepare for surgery, you’ll need hair removal services and that might be both laser and/or electrolysis depending on your hair type.  You’ll need a referral from your surgeon and it’s important that you get the right hair removal services so that your surgeon has a clean area with which to work and so there will be minimal clean up after surgery.  If this step is not handled with care, you may not be able to fix the issue of hair in unwanted places after surgery or possibly delay your surgery. 

Since hair grows in cycles with dormancy in between, you’ll want as much lead time as possible for hair removal and remediation if some hairs grow back.  It is best to begin hair removal at least one year before surgery. If you can start earlier, that is better. Hair removal only a few months before surgery may work, but you may need additional hair removable later. It is very important to find a hair removal specialist who is well versed in surgery preparation. This person can also be an ally, which is super beneficial and reassuring.

Your surgeon may be able to support you with a list of recommended and safe practitioners to see.   Note that not all hair removal practitioners will be willing to work with you or accept your health insurance.  If you want the hair removal covered by insurance, you need to verify that the provider is in-network with your health plan. (Caution: Some providers will say they accept all PPO plans. This doesn’t mean their services will be covered as in-network by your PPO plan. It means that you will pay the full rate for the service and the expense will accrue to your out-of-network deductible.)

Surgeon

The entire process of gender affirming surgery is intimate. Perhaps the most important relationship that you’ll want to secure is with your surgeon. Your health plan (Medi-Cal, Medicare, individual & family, employer group) will have a network of surgeons in the network. With luck, your preferred providers and surgeons will already be in the network of your health plan. Each health plan maintains an online list of providers for members to search. Healthcare networks are still learning and catching up with how to provide services to the transgender community. 

In the case where your network can’t provide you with a surgeon, you’ll have to find your own and a good place to do that is within your transgender community along with searching online.  Once you have an idea of who you might like to work with, it’s a good idea to do some research about the reputation of the surgeon you have in mind.  Explore the surgeon’s website, note the questions you have requiring answers, and how you feel as you explore options.  Look for and follow links, read articles and papers in which your prospective surgeon has participated or written.  Consider whether or not your surgeon is up on the cutting edge of new surgical techniques, how long they have been practicing and whether they may even be an innovator in their field in their own right.  A growing number of surgeons are themselves transgender which offers them a unique perspective.  Do your homework in advance and then set up a meeting coming prepared with questions to ask.

If it turns out to be the case that your network isn’t able to provide a surgeon for you, you’ll need an out-of-network referral to be able to work with the surgeon of your choice.  Find out in advance by asking your surgeon if they are able and willing to work with your network. Some health plan types are more accommodating to out-of-network referrals than others.

Transgender Clinics

Some healthcare networks are beginning to have clinics available that specialize in transgender services.  Such clinics can be staffed with allies and are more knowledgeable with respect to the needs of the trans community.  It is more likely that the clinic will know how to direct you and can save you time cutting through red tape and sometimes even fast track you to where you wish to go.  Kaiser in Oakland and San Francisco as well as UCSF each have specialized clinics.

Member Services

Your health plan’s member services division can be a helpful stop when pursuing transgender care.  When first signing up with a health plan, you can call member services and ask if they have a list of practitioners who are not only allies with the trans community but also knowledgeable about safe language, trans issues and, perhaps more importantly, trans bodies and their needs.  Consider making member services your first stop when joining a new health plan to get plugged in to the care you desire in the most expedient way.

Switching Insurance Networks

Not all health insurance plans and networks are created equal.  You may find that your gender affirming surgery and attending services can be sped along by switching networks either before seeking services or along the way. The difference between talking to a network, “specialist” who has helped one transgender person move through their process or many if not hundreds can make a huge difference in time, finances, peace of mind, body, esteem, and ultimately wellbeing.  For example, moving from a network that does not have a specialized transgender clinic who covers and can fast track you to services such as facial electrolysis for MTF patients to one that does.

With HMO health plans, your selected Primary Care Physician (PCP) will first refer you to specialist in the PCP’s medical group. You may have to change PCP’s, affiliated with a different medical group to obtain a referral to the specialist of your choice. However, you may lose your preferred PCP. With persistence, you might be able to obtain a referral to a specialist out of your PCP’s medical group. This will have to be done in cooperation with the PCP and the health plan.

Forging new ground?

At some point on your journey, you may be asked or simply find yourself in a position facing whether or not you are willing to forge new territory or a path for healthcare services for yourself and possibly others.  Sometimes the inquiry may be easy, for example working with a new PCP who has never written letters for a trans person but is willing to do so.  In this case, knowing the letters you need ahead of time, including meeting requirements for your insurance carrier, can be key and even ease your process. (Each health plan will have a medical policy document that outlines all of the steps, rules, and necessary documents and letters for prior authorization of gender affirming surgery.) At other times you may be asked to be involved in something larger than your own personal care that can really slow down your process.  In that case, you’ll have to decide whether your goal is speeding your transition journey along, greater trans advocacy, or both.

Whether you need someone to formally advocate for you, a little hand holding from time to time or just knowing that there’s someone that has your back that you can call on, if need be, advocacy goes a long way.  Remembering that there is a way through, over, under or around obstacles can be helpful and not only do you not have to make your journey all by yourself, you won’t be alone.  Along the way you will meet many people who will not only help you on their part, but who also likely know other good people who you can be referred to who can help you.  Online support groups such as the Facebook Transgender Alliance with 26K+ or other online communities can be great resources for help.  The therapists who write your letters are often either available for follow up chats or will likely be plugged into a network of resources you can access. 

How difficult is it to make all of the arrangements for the multiple procedures? Should one expect the doctor’s office to assist or is it all up to the individual?

The ease of obtaining multiple services can vary greatly over time and depending on the network and how effective and prepared you are when seeking services.  It can be helpful to remember that you are running a marathon rather than a sprint, so pacing is important although sprinting may be necessary at times.

Beginning with yourself as your own advocate, be prepared and create your own file folder and system for moving smoothly through the process effectively.  Collect and keep copies of every document your experience generates and take them with you to all appointments even if you are told that you will not need them!  Consider preparing copies not only for yourself but also for your care providers when you are likely to need them. This can save you minutes or days of precious time and frustration.

Specialized clinics are more likely to assist you than a health plan itself. But in general, do not expect assistance as much as empowerment about your mission. Educate yourself as best as you can in order to anticipate and understand the process for both prior authorization of the surgery and preparation for surgery. There are times when certain parts of your journey – for example when you contact your surgeon for the first time – when you may be given better instructions than at other times because of the nuances involved in receiving a particular service. When in doubt, ask questions and ask for clarification.

There is a flow that you will find to obtaining services that begins with talking to a practitioner, getting a referral, securing approval for your procedure and then finally making an appointment for the service that you are after.  At any point in that process, you may need to follow up to nudge the process along.  There may also be subsequent approvals that you need for example hair removal before surgery, etc. 

Ultimately know and move into the reality that you are the final backstop for your own care and the person who has the vantage point of seeing as much of the complete picture of your care as possible.  It is helpful to starting early in the window of your opportunity for the procedures that you are pushing for as the process can take longer than you think and your emerging need for services are not necessarily a priority for others.  You may run into practitioners being on vacation, calling in sick, or perhaps even leaving a clinic or network. 

For example, if a therapist leaves a clinic and is no longer available to update a letter that you require, you may need to find a new therapist and begin establishing a new relationship.  Fortunately, in the case of needing a new therapist, if you’ve received a letter in the first place, a new therapist may write you a new letter in a single visit after reviewing your initial letter.  Sharing kindness, appreciation and gratitude can go a long way to help you move forward easily especially if you need to double back and require additional help. 

How do you go about finding a surgeon you feel comfortable with performing the surgery?

With any health insurance, your first stop for finding your surgeon(s) will be the network of providers contracted with your health plan to see if they are able to provide you with a surgeon.  If the health plan is able to provide you with a surgeon, you can research the practitioner and see if they are someone from whom you are able and willing to receive services.  It is important to note that some surgeons may not actually have experience working with transgender folks such that you may have grounds to request a different practitioner. 

You may be referred to a surgeon who does not perform your requested surgery at all or the network may not have anyone who performs the surgery you desire, period.  In these later instances you will likely need to research a surgeon completely on your own and ask to be specifically referred to surgeon of your preference.  Online research and asking your transgender community for support to find a surgeon can be very helpful.  There are a growing number of surgeons who are performing gender affirming surgery.  If you are having trouble finding a surgeon in your area, reach out to what surgeons you are able to find and ask for referrals from their office to someone in your area.

It is important to note is that MTF and FTM surgeries differ in complexity and methods and may require multiple surgeons and surgeries including revisions.  There may or may not be skin grafts required which in themselves may require additional hair removal services or other prerequisites. 

How is follow up care with the health insurance and doctor’s office?

Follow up care varies not only by health plan but also at what stage you are in with respect to your surgery journey.  You may experience much less to no follow up when pursuing letters for example and much more follow up when approaching a surgeon.  Surgery requires initial consultation for example to make certain you are a good candidate for the procedures you desire and that you have your therapist letters in hand.  There are referrals and approvals to be had and eventually one or more pre-operation appointments with your surgeon and/or staff.  After surgery there are post-operation visits and follow up both in and out of office.  Follow up care may extend to a year after surgery from your surgeon and also transition to more general care.

Post-surgery you’ll want to make certain that your practitioners are familiar with trans bodies.  For example, MTF gender affirming surgery may need to receive mammograms or see a gynecologist for the first time.  You’ll eventually settle into general care from your PCP who can also support you with monitoring your hormone levels going forward.

Finally, another way of looking at following up with medical providers is how you follow up with them.  Consider writing a note of gratitude for your care provider not only to say, “Thank you,” but also to help pave the way for other transfolk in your community toward being held in a good light.  Perhaps you are leaving one medical group network for another so a quick note to your PCP letting them know you are moving on provides a kind experience for them instead of being ghosted.  This last bit can be a quick and easy way to be a trans ally for countless people in your community whom you will never meet but have helped.

Take care when deciding if you’re really the one to forge new ground when it comes to pursuing transgender services.  In some instances, it can be rewarding to do such work and at other times you may become disheartened, so choose wisely with respect to your advocacy for self and others.

Final points to emphasize:

Thank you Julie for sharing your valuable insights.