Transgender Health Insurance Basics

By Faye Seidler

Insurance can be an incredibly confusing and complex thing for anyone, but it gets even harder when a person has unique medical needs that aren’t always obviously addressed in a coverage plan. As such, I’ll be covering the basics of what to look for in insurance coverage and what it means for transition related care. I’ll also be going over what each public health insurance company in North Dakota covers in terms of transitioning services.

Keep in mind that even if someone has insurance through work, if the workplace insurance doesn’t cover transition related care, it may be worth your buck to drop out and buy a public plan instead.

Learning how to understand insurance doesn’t take much more than learning these four terms: premium, copay, deductible, and coinsurance. The premium is simply a person’s monthly insurance bill. Copay refers to a fixed cash amount for a service that often appears in the format “$10 Copay.” That means regardless of what the services cost, a person in that example would only pay ten dollars for it.

The deductible is the amount of money a person needs to spend on healthcare before their health plan’s benefits kick in, which typically means their co-insurance is activated. Now, co-insurance is a term that refers to the fixed percentage of a medical bill you have to pay. Typically, this would appear in the format “10% co-insurance” and in that case would mean a person only had to pay 10% of their medical bill. But keep in mind, that is only after the deductible has been paid. This continues until an out-of-pocket maximum is reached, and then insurance covers 100% of covered services in network.

For transgender individuals looking for transition-related care, there are four really important areas to look at for coverage: prescription drugs, mental/behavioral health, specialists/endocrinologist, and surgery. If your insurance doesn’t cover prescriptions and you need them, add $30 to the premium. If it doesn’t cover specialists, add $50. If it doesn’t cover therapy, add $30. This means a transgender person who has insurance that doesn’t cover these services could be paying an extra $110 a month compared to a plan that would.

But that all pales in comparison to the $10,000-$20,000 surgery would cost without insurance, a price so steep that pretty much any plan a person can buy that covers it, would be cheaper than having to pay for it themselves.

Unfortunately for transgender people, there are two layers to look at when looking at insurance coverage. Does the plan offer the coverage and does the plan offer that coverage to transgender individuals? Many private plans make blanket exclusions for transgender-related healthcare, so even if it does look like it covers those services, it may not cover them for trans people. The only way to know is to call them or look at your comprehensive policy.

Now, since there are many healthcare plans you can only have access to as a student or employee, I focused on all the plans any individual could purchase as a resident of this state. While I did my best to represent these companies honestly and accurately, please verify any coverage you’re looking for through the insurance companies first.

While Medicare isn’t public to everyone, it is worth noting that it does cover all transgender-related care, including surgery. Medicaid has a gender reassignment surgery exclusion. I don’t know for sure what it covers, but speaking with community members who have it, it seems like it will cover therapy, endocrinologist visits, and sometimes hormones.

Sanford Health Plan representatives indicated that counseling, hormones, endocrinologist visits, would be covered given the plan covers them. Blood work may be covered if preventive care is, but hormonal blood work would require hitting deductible first. They also do not cover transition-related surgery in their plans that anyone can purchase.

Andrea Dinneen, Public Relations & Internal Communications Manager, Public Affairs, at Blue Cross Blue Shield of North Dakota, indicated that their plans at the beginning of next year would be Affordable Care Act Compliment and not make any blanket transgender exclusions for services. They did not specify which services were covered or not, but here is an exclusion written into their Bluecare Silver 70 plan that says: “Treatment leading to or in connection with sex change or transformation surgery and related complications.” This could mean they don’t cover hormones, endocrinologist visits, or surgery. However, they said none of their policies on this subject have been finalized and there is hope they could cover these things in the future.

Gary Bury, Sr. Manager, Public Relations & Social Media, at Medica, indicated hormones would be covered if deemed medically necessary and appeared on their list of preferred drugs. There are no blanket exclusions for endocrinologist care if it is covered, but their plans wouldn’t cover the associated bloodwork with monitoring hormone levels. However, they explicitly exclude surgery as part of their plan.

That said, if you need coverage for surgery in North Dakota, you have to find a job that offers it, college that does, or you have to move. I recommend moving to Minnesota for much more inclusive transgender healthcare. Specifically, Minnesota Medicare now includes surgery within their benefit policy, which is especially useful for those in poverty or with low incomes.

Additionally, the good news is that if you move it counts as a life-changing event, which allows you to purchase new insurance through MNsure right away. So, even if you move months from now, you’ll still be able to qualify for Minnesota based health insurance.

[Editor’s note: Faye Seidler is the North Dakota Safe Zone Project Spokeswoman]