Kaiser’s New Policy In Response to DMHC’s Ruling

As I wrote about earlier, California’s Department of Managed Health Care (DMHC) has ordered California’s health plans to remove exclusions of coverage based on gender identity and expressionKaiser is the first I’ve seen to release more information about what they are specifically doing in response to these changes.

I couldn’t get my hands on an official document or website that outlines these changes, but I have been speaking with a couple of Kaiser representatives who have been answering my questions about the latest developments re: Kaiser and surgeries/treatments for transgender individuals. Part of this comes from an internal Kaiser document, so I did not post it in its entirety. If you have questions about  your specific Kaiser plan, the best thing to do is call member services at 800-464-4000.

Here are the main points:

  • The transgender benefit includes sexual reassignment surgery and mastectomy/chest reconstruction services, in addition to behavioral health and hormone therapy services. 
  • hysterectomies/oophorectomies are included as covered procedures in “bottom surgeries” for FTM individuals. If a hysterectomy is medically necessary for other reasons, surgery is covered no questions asked. If this surgery is pursued as it relates to gender transition, the surgery has to be reviewed by the “transgender surgical review board process”.
  • MTF breast augmentation is not a covered benefit
  • Cost sharing for these services is the same as cost sharing for other medical services for the employer group or individual’s plan (e.g., inpatient hospital cost share, office visit cost share, etc.).
  • The benefit has no lifetime dollar cap on services, even for employer groups that previously purchased KP’s optional transgender surgery rider that included a lifetime dollar cap.

What other KP lines of business include transgender benefits?

  • Medi-Cal
  • KPIC insured plans, based on regulations issued by the CA Dept of Insurance (KPIC is currently determining the scope of transgender benefits required under the regulations)
  • Benefits in these plans are not affected by the DMHC April 9 directive.

Which plans and market segments are not in scope for transgender benefits at this time?

  • FEHB
  • Medicare (except for Group KPSA (Kaiser Permanente Senior Advantage) plans in instances where the employer group has purchased optional coverage for transgender services)
  • Self-Funded employer groups (except for self-funded groups that have specifically elected to cover transgender services)

What travel and lodging is covered as part of the transgender benefits?

The travel and lodging is covered for:

  • ·      NCAL members traveling to Arizona
  • ·      SCAL members traveling to either Arizona or San Francisco

Are other states taking similar action?

  • Yes.  Regulators in Colorado, Oregon and the District of Columbia have taken similar action as in California.  No determinations have been made in those regions yet in terms of immediate action steps or changes to practice.  Other states may take similar or different action in the future.

Southern California Contact:  TransgenderCare@kp.org

Northern California Contact: Terri Hupfer Terri.Hupfer@kp.org

www.kp.org/eastbay/transgender

Not sure what your insurance company is doing about this? Call them! Ask them how their policies have changed and what procedures are now covered. Please, let me know what you find out at tandotherapy@me.com.

Update 8/1/13: Matt Wood of the Transgender Law Center offers further explanation and clarification:

Kaiser is an insurer, and as such it offers a variety of plans.  It’s important to help people understand the difference between a plan and an insurer.  In the past, certain plans included care for SRS, and certain ones didn’t.  So people used to call me and ask if they should insure themselves with Kaiser or Blue Cross, because they heard Kaiser offered trans care. The truth of the matter was that all insurers offered all care – it just depended upon what plan you or your employer contracted for.  We have argued all along the while exclusions themselves weren’t unlawful, those based upon gender identity were. The problem was that Kaiser and other insurers had exclusions that were worded as if they solely applied to trans people (“no care related to transsexualism”) as opposed to exclusions based upon procedures (“no hysterectomies”).

As a result, the DMHC issued its letter saying that all medical care that is medically necessary for gender transition and that is available to non-trans people cannot be excluded. There’s no distinction between MTF and FTM care, or bottom and top surgery. All *could* be covered, depending upon a person’s unique medical circumstances.  But we’re hearing right now that they don’t want to do any trans related surgeries for people with plans that formerly had exclusions until they have received more information from DMHC. We’re not sure why this is. We expect to get more clarification within 6 months, but that is a huge burden for many people with HMOs, not just Kaiser.

Medi-cal is different.  Medi-cal is a federal program administered by states at the county level. Medi-Cal has never excluded transition-related care (top, bottom surgery or HRT). However, depending upon which provider the county contracted with, that provider might have been misinformed and told a person there was an exclusion.  Some people have Medi-Cal through HMOs. Some have it through fee for service (find their own doctor who accepts and get reimbursed).  The affordable care act will make it more likely that people will have HMOs.  Some counties contract with Kaiser (esp here in the Bay Area). But other counties don’t.  But Exclusions don’t now, and haven’t in the past, been a legal barrier to care. Barriers have been ignorance of providers and lack of available providers (those that accept medi-cal reimbursement rates, which are supposedly among the lowest in the nation).

The Director’s letter applies to *all* HMOs, not just to Kaiser, as well as to all plans – including those offered by employers and schools, as well as those purchased by individuals. The only exception is that it does not apply to HMO plans that are offered by companies that are to “self-insured.” Many large companies are self insured, so check your plan carefully. If your company is self-insured and offers an HMO plan, it is not subject to the Director’s letter.

What this means:
1) An HMO cannot deny to a transgender patient the same medical procedure it covers for a non-transgender person. So if an HMO will cover a non-trans person’s hormone therapy for some medical reason, it must cover hormone therapy related to gender transitions for trans people. Similarly, if an HMO offers genital surgery to a non-trans person for some reason, it cannot deny it to a transgender person who seeks it as part of their treatment for gender dysphoria/GID.

2) HMOs are not required to cover all types of transition-related care. Rather, they are required treat trans and non-trans people the same in the provision of covered care. So, for example, if an HMO does not provide coverage for a hysterectomy for a non-trans woman, then it does not have to provide coverage for a hysterectomy for a transman based upon his gender transition.

3) HMOs offer “managed care” and a primary way they save costs is by contracting with specific physicians and surgeons. These medical professionals then become part of the HMO’s “network.” As a result, if the HMO already has someone in network who can perform top surgery or GRS, then you must use that in-network provider. If you want to go to a specific surgeon that you choose, ask them first if they are part of the HMO’s network. If they are not and you still want to go to them, you’ll have to pay for the procedure out-of-pocket. In some rare cases, as deemed appropriate by the HMO and based upon a person’s unique medical circumstances, the HMO may choose to cover medical care by a provider who is not in its network.

4) Finally, there is still much confusion about what the Director’s letter means, and we are aware of transpeople who are still being denied covered care by HMOs. If this happens to you, please contact the Transgender Law Center at 415-865-0176 x306 or online at: http://transgenderlawcenter.org/help

To read the Director’s letter and learn more, go to TLC’s website –http://transgenderlawcenter.org/archives/4273

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Published in: on June 21, 2013 at 2:46 pm  Comments (17)  

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17 CommentsLeave a comment

  1. Has any progress been made on making FFS/electrolysis requirements explicit? These seem to be common sticking points, even when GRS and whatnot are hypocritically included separately from other non-genital transition procedures.

    I do love how insurance often covers testicular implants and remarks that they are “not cosmetic” while somehow FFS is “primarily cosmetic”.

    • Very interesting points! I do have some updates to my original blog post that I will add shortly. One thing I now understand about what insurances will cover in regards to gender transition is that if they don’t provide the procedure for other conditions, they won’t provide for transgender patients, even if determined medically necessary.

  2. Hello,
    I read you very informative article, thanks for writing it!
    I’m afraid that I might have misunderstood… I have MediCare due to disability. I live in CA. I’m 49 years old. Do I qualify for gender reassignment surgery?

    Best Regards,
    Chris

    • Hi there,
      Yes, MediCare theoretically pays for surgery related to gender transition. However, the biggest challenge is in finding a surgeon who is skilled at this type of surgery and who also takes MediCare. One option would be to get approval from MediCare prior to the surgery for an out of network surgeon, pay the surgeon out of pocket and then try to get reimbursed for part by MediCare. The biggest issue with this is that most individuals don’t have the money up front, and there is no guarantee MediCare will reimburse. 😦
      Warmly,
      Darlene

  3. I heard somewhere that you need proof of being trans to be covered for trans operations. I was wondering if I missed this or if it wasn’t covered and either way what then would be the story for that issue? Please and thank you!

    • Hi Alyx,
      Just the word “proof” alone is enough to make me cringe, I hate the idea that transgender individuals have to prove anything to get the care they need. That said, most surgeons and insurances want the patient to be diagnosed with Gender Dysphoria in order to provide/pay for medical transition. I try not to give the diagnosis at all since I disagree with the fact that it’s in the manual of mental disorders, but I will put it on my clients’ paperwork if the doctor/insurance insist I do so…
      Let me know if you have any more questions!
      Warmly,
      Darlene

      • Thank You!

  4. I am writing to see way you have to have a letter for your SRS, when you now you or truely a male to female or a female to make. All i know is that i am a female trap in a body that i hope to God i don’t die in I now that 100% that i want the SRS and it’s who i am to be a woman and if i die on the operating table for the SRS i know i will be a female and be who my true self is and happy knowing that i am female

    • Hi there,
      I know, it can be so frustrating that someone has to give the green light to something you KNOW is right for yourself!!
      The purpose of the letter is to show that you have been evaluated by a mental health professional and you are of sound judgment and mind to make a decision such as medical transition/surgery. In my opinion, that is all that it is good for, because everyone knows their true gender and has the right to access medical interventions based on that. Good luck my dear!! Darlene

  5. I have a problem with my employer. They offer a self funded health insurance plan thru United Healthcare which I enrolled myself and my transgender son in, (who is 19). I wasn’t even aware of what “self funded” was and did not find out until Dec. after I called UHC to see if they covered GRS. However, once the rep told me the plan was “self funded” which meant it doesn’t have to follow state mandates for coverage, I was upset. I asked my HR Rep at work to contact Corporate & expain the situation and ask if they could please either add GRS to the policy or have him removed, since this insurance does not benefit him, as it will not cover any of his hormone treatment or surgery. The HR Rep locally said she contacted the corporate office (of my employer) located in TN, and they refused to add on GRS (gender reassignment surgery) to the policy and said they don’t have to since it’s self funded.. I understand that, and was hoping they could take him off of my plan, but they won’t remove him & I’m still paying for him to be on this plan. I want to purchase individual policy for him outside of work and can’t do this unless they remove him from the plan as this causes issues with insurances. If you have any advice or point me in the right direction as to how I can get help, please let me know. I’m located in Boston, MA.. Thanks, Sheila

    • Yes, I unfortunately found out about the self-funded insurance loophole about a year ago. So disappointing! Why will they not remove him from your insurance? Is it an “open enrollment” type thing, where you have to wait for that to make changes to your plan?
      Removing him and shopping for a different insurance plan is the best bet, but I know you can’t do that until he is removed from your current plan!

    • I don’t know why they won’t move him. The HR rep said it’s becz just becz I want to remove my son is not a “qualifying event” but I feel since the plan doesn’t cover transgender svcs it does not make sense fir me to pay for my son to hv this insurance. I would hv to get him a separate plan in order for him to hv his hormones & surgery covered. I will cl Corporate myself next wk or write a letter explaining all of this. There shld be a loophole or special considerations or maybe a rider -something should be done.

      Thks
      Sheila

      • I am going to ask someone who knows a lot about insurance about this and get back to you!

      • Hi Sheila,
        Sorry it took me so long to respond! I finally talked to the insurance rep I know. Now, he knows most about CA insurances but here is how it works here:
        If a person has the minimum standard of healthcare, they are required to keep it or pay a penalty. They cannot drop it and get another one until Open Enrollment, unless there is a qualifying event. That would be something like citizenship, marriage, losing insurance from a job, etc. Open enrollment in CA is November, for “Covered California”, with a January start date. I agree with you that in this case a special consideration should be filed. Any movement on this??
        Warmly,
        Darlene

  6. Unbelievable. By your report, her report, or any other behavior does she show any ambivalence about surgery?? Even IF she was inconsistent about taking her medication, it does not mean she does not want the surgery. How frustrating! Where do you live? Private message me and give me more details. I am happy to call and discuss this with her providers. tandotherapy@me.com

  7. I really wish I found this site sooner. Love what you are doing.

    How do you know which Kaiser plan covers GRS? I am a self-employed small business owner; and I’m picking up insurance for my Trans Partner (MtF) and her child. I want to make sure Kaiser will pay a significant amount lot of her surgery, 40 or 60%. How can you find out about coverages? It’s Bronze 60 HSA 4500/40% or Bronze 60 HMO 5000/60%

    • Most should be covered through Kaiser and then depending on the plan they will pay whatever percentage you choose. If you know she is going to have surgery, try to pick a plan that has a higher monthly fee (for now) and a lower deductible!


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