It states, "we did receive a full authorization for your pending surgery"!!!!!!
My surgery is 36 days away and my partner and I are driving down together in less than a month, so needless to say I was nervous that we were making all of these plans (and putting down a non-refundable deposit on airbnb) and that the rug might get pulled out from underneath us.
How'd we get here?
I work for an organization that is self-insured. This means that they determine their own coverage and work with an insurance company to serve as an administrator. In most cases, this works to the benefit of the employee because (a) if that employer has a large population of "healthy" people on its payroll, the insurance premiums are generally lower and (b) they usually cover a wider range of services and are less likely to nickel and dime providers.
Two years ago when I sought coverage for my metoidioplasty, the organization had listed "transgender surgery" as an explicitly excluded service on the insurance policy. Without going into it (cause I could), I assisted in ushering through a change to this policy. We were, and still are, using Cigna as our insurance administrator. At the time, the rider that Cigna provided for gender confirmation surgeries was very limited and didn't cover FTM bottom surgeries. Had I not been the one pushing for this change while seeking bottom surgery, it is possible that they may have chosen to use Cigna's rider not knowing that it was so limiting. Since Cigna didn't have a better option, my employer chose to go with the policy that anything listed under the WPATH Standards would be covered, with no maximum or lifetime cap. This was a very clunky process where Cigna initially rejected my first round of claims because they hadn't yet added the right procedure codes to their system! (Not fun on my end. I guess this what comes with being the 1st.) Putting my criticisms of WPATH aside, this was a huge success, and it means that any progressive changes that WPATH makes will immediately be available to employees at my organization. It also sets a precedent for other self-insured organizations that chose Cigna as an administrator.
Insurance Pre-authorization
The paperwork for pre-authorization is submitted to insurance companies no earlier than 90 days prior to surgery. From what I know, the pre-authorization only holds for that 3-month period, so if someone was to get approved earlier than 3 months in advance, the process would need to be repeated.
Side note: This is nerve-wracking for those of us who are traveling hundreds to thousands of miles for surgery. I started making work and travel plans without knowing whether or not this would pan out.
I received notice on September 28, 2016 that I was scheduled for my Phalloplasty with Crane in Austin, TX on December 1, 2016. At this time I paid an additional $150 fee for them to oversee the insurance coordination process and put down a $2,000 deposit for the surgery. This is required to confirm and set the surgery date and was due within 5 days of receiving my surgery date.
Approximately 3 weeks later, the insurance coordinator at Crane's office, Selena, prepared all of the paperwork and submitted my case to Cigna - on October 20th. (FYI - Selena was very helpful and responsive to emails about the status of my case). On October 24, 2016, I received a letter in the mail from Cigna stating that they were seeking more information on the service "Treatment for Skin Graft (15757)" and had submitted a request to Crane's Office. I emailed Selena who said they had already received and responded to the letter with more information.
Oddly, I was very stoked to get this letter. First, it meant they were already deep in the process of reviewing my case. And second, the one service that got flagged for them seemed to be a pretty innocuous one. Had something like the scrotoplasty or phalloplasty gotten pinged, I would have been really nervous. Within a day of receiving this letter my case was fully approved by Cigna. With the time difference, I didn't end up seeing the email until this morning.
UPDATE: I corresponded with Selena today who said that they are in the process of negotiating payment with Cigna and she submitted an in-network exception. Their goal is to have my surgery processed as in-network and obtain a single-case agreement. If this works out, this will save me about $2,500 of out-of-pocket costs - the remainder of what I owe this year towards my out-of-network out-of-pocket max. I've already met the in-network max ($2,250), which would mean smooth sailing. My fingers are crossed so hard.
A Note on Health Insurance
This surgery is entirely cost prohibitive for me and many others without insurance coverage. A complete phalloplasty with urethral lengthening, vaginectomy, scrotoplasty, and testicular implants lands in the range of $85,000. There is no way that this is even moderately affordable for most trans men. It also requires (for Stage 1) a 4-week post-operative stay and 8-12 weeks recovery time. I am fortunate to have my salary covered at 100% for 8 weeks and then at 60% for the remaining time I take off and to be eligible for FMLA, which basically protects me from getting fired for taking up to 12-weeks off of work. At most places, employees need to be employed for a full year before being eligible for FMLA protections. As my partner and I are not married, he is not covered and was fortunate enough to work out an agreement with his supervisor to work remotely while he is in TX caretaking me.
According to the National Transgender Discrimination Survey, trans people are unemployed at twice the rate of cis people (14% vs. 7%, and double that for trans people of color), underemployed at 44%, and our rates of poverty are significantly higher than the national population. 27% of respondents reported an annual income of less than $20,000 and 15% reported an annual income of less than $10,000 (compared to 7% at $10,000 for nat'l pop.) On average, trans people are uninsured at the same rates as the national population in the U.S. (19%!!!), but only 40% received employer-based insurance coverage compared to 62% of gen pop. Additionally, Pooja Gehi and Gabriel Arkles, found that Medicaid policies had been excluding and/or limiting transgender health coverage. While the NTDS survey is from 2011 and the Gehi & Arkles study from 2007, it is possible that the access to healthcare for trans people has shifted for some of us, but certainly not all.
We need more advocacy so that trans people are employed and paid fairly and equitably. We need more surgeons who are willing to work with insurance companies. And, we need full health insurance coverage for all. Without it, we are willfully letting people suffer and die.
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