Hi everyone my name is Chris man my pronouns are in his and I'm the program manager for UCLA gender health program today's webinar is titled insurance navigation 101 before we dive in I just want to remind everybody that you're free to ask questions via twitter using the hashtag UCLA md chat so now.
For a brief overview before I get into it I just want to say that navigating insurance can be very challenging and very frustrating at times so my hope in doing this webinar is to help clarify some information and hopefully you'll learn something new about how to navigate insurance one of the other things that I want to mention is that.
This insurance will look broadly at the various types of insurance but also be bound to the state of California to get into all of the other states would be a series of other webinars and today we're just going to focus in California but at the end of course I will give you resources that you can look to to look at other states and the insurances that.
Are based in there of course we're going to go over the various types of insurance that exist out in the market and then also look at how you can look into accessing gender affirming care through your insurance so I wanted to start off with this slide from the HRC or the humans rights campaign because this underscores how gender affirming.
Care really does vary state by state the deep blue represents states that that bans specific exclusions in insurance for trans healthcare as well as offer really comprehensive and inclusive health benefits for trans folks if they're a state employee the medium blue corresponds to states who offer trans exclusions in their in their insurances.
And then the light blue represents states that excuse me provide inclusive benefits for state employees so again it really does vary on where you live in the United States so it's always important to keep that in mind so now we're going to get into the various insurance types so health maintenance organizations or HMOs are really common.
Preferred provider organization PPO s Medicaid which is state-based health insurance in California ours is referred to as a medical we also have covered California which is kind of the on exchange meaning that folks can purchase this on their own accord and then Medicare which is a federally state-funded health insurance.
Program and we'll get into a little bit of what each of those are as we go on through the presentation of course in navigating insurance and what makes them a little bit challenging is the terminology so I think it's really important to start there first the premium is the monthly payment that you make to maintain health insurance.
Generally if this is offered through your employer it'll be taken out of your check if you are purchasing it on the exchange you know you will pay out of pocket each month and then if it's government based insurance whether it's Medicaid or Medicare that'll kind of vary but generally that's offered at a really.
Really really low cost so again out-of-pocket expenses is what you pay in accessing health care so that's kind of the umbrella term that includes your deductible your co-payment and your coinsurance the deductible is the amount you pay before your insurance kicks in so that kind of varies depending on the plan that you have but generally it's a.
Couple of thousand dollars then once you reach that cap your insurance will kick in and start paying for everything from that point on but there are some variations again that's what makes navigating insurance a little bit tricky so that each kind of policy in plan is a little different the co-payment are also known as the copay is the amount that.
You pay every time that you access care so if you go into a primary care appointment it'll be anywhere from like fifteen twenty twenty-five dollars it's definitely lower than what you would be expected to pay if you were to pay for the entirety of the appointment coinsurance is the percentage of the bill that you are responsible for so.
Again just because something is covered by insurance does not mean that it is free so if you're looking for gender affirming surgeries you will be responsible for some pay in network is also going to be very important so in network are doctors surgeons health organizations that take and accept your health insurance and again it's going to.
Be really important for you to know that so if you're looking for a specific program a specific doctor you're going to want to make sure that when you're approaching insurance that you're asking if this health system if this surgeon is a network out-of-network of course is the opposite so if they're not in network they will.
Be out of network so folks or health systems who do not accept your insurance it's now getting to HMOs so HMOs are generally offered through employers and on the exchange premiums are generally lower so the amount that you pay each month and the deductible is usually lower you will be required to pick a primary care provider and if you don't.
Someone will be assigned to you someone that is in network HMOs kind of function as a mother mae-eye approach in order to access specialty care to go to a urologist ob/gyns you'll have to get what's called a referral so you have to go in for an employment with your pcp explain to them what service or where you would like to go and in regards to.
Specialty care and then your provider will then send a referral out and then your insurance will authorize it once you get that authorization you're then able to access the care that you need in a specialty care setting if you're accessing care outside of network it can get pretty expensive so it's always going to be really important to stay.
In-network and then again if you're purchasing on the exchange or through covered California there's going to be certain tiers and those will vary about how much your premium is out of your out-of-pocket expenses so it's really going to be important for you to check those out PPOs again like HMOs are generally offered through your employer.
Or on the exchange as well premiums and out-of-pocket expenses are generally higher deductibles do vary but there is greater flexibility in getting the care that you are looking for with PP o–'s you do not need to get a referral to access specialty care so whenever you're ready for that consult whether it be for top surgery bottom surgery or just even.
Routine care through a specialist you can go ahead and call and make appointment without getting that referral so some folks do choose to go the PPO option if it's within their means also if you choose to go out-of-network there's generally better coverage but it's always recommended that you stay in-network and again if.
There's a specific doctor Health System that you're interested in going in it's going to be really important that you ask if the PPO insurance that your look two is accepted at that office and again the scene with HMOs if you're going through the exchange there is a tier system which will also impact again premiums out-of-pocket expenses so again.
It's really important for you to do your research so I've been mentioning covered California so covered California is the exchange or the market for health insurance here in California it provides health insurance coverage for folks who maybe don't get it offered through their employer and do not cover for medical again there's a variety of H HMO and PPO.
Plans from a variety of payers and again plans do vary based on bronze silver gold platinum etc the open enrollment period to get enrolled in covered California is generally November through December but for more information you can go to cover California comm and then also for other states you can go to healthcare.gov as well so again it'll.
Give you all the information that you're looking for and yeah it's a really good place to get that health care if your employer doesn't provide it and you don't necessarily qualify for Medicaid Medicaid or medical here in California is state government health insurance you must be a California resident in order to access medical it provides health.
Insurance for children and adults with limited monthly income and resources so you have to meet a certain threshold for more information go to medical dot ca.gov again I think they believe they have a calculator they have some kind of system that will let you know if you qualify for it you can also go to local.
Department health care services offices so that resources here and it is important to mention that medical does cover gender affirming care and surgeries so again if you're looking for hormone replacement therapy top surgery bottom surgery any kind of surgery it's really going to be you can get that care through medical another defining.
Characteristic of medical that's important to note is that they will assign you to somebody who will be your primary care physician and like an HMO you do have to go to them before you seek specialty care or surgery consult Medicare Medicare is a federally funded health insurance program for folks 65.
And older or who have chronic health conditions or certain disabilities it's accepted by most care providers in most health systems Part A Part B Part D so this will be really important because I think you can opt in and out of which ones that you want but generally those are the three that most folks will look at if they're pursuing Medicare coverage.
Medicare does cover medically necessary hormone treatment and some gender affirmation surgeries so again it's really going to be important for you to be really connected to a team that knows your care and knows your insurance and helping you navigate what your health benefits are again there is a Medicare website that is out there so if you do a.
Quick internet search you'll be able to find exactly what it is that you need in accessing gender affirming surgery it's going to be very important for you to know the world professional association for transgender health or W path they publish a standards of care document that pretty much outlines any kind of medical surgical or mental health care.
That you might be seeking as a trans or gender diverse identified person what's important to note though is that these standards of care are really seen as guidelines nots law but what makes this really important for this talk in particular is that a lot of insurances base their insurance coverage and what it is that you need to access gender.
Affirming care based off of these standards version seven is currently up and I believe version eight is slated to come out sometime this year but we'll see so if you've never heard of this document I really would encourage you to look at it as a patient and a provider because as a provider it also gives insights on how to deliver gender.
Affirming care so it's a really great robust document also it outlines what needs to be put in the letters that are required for gender affirming surgeries and we'll get into a little bit of that later so again so now we're going to talk about gender for main care in general through insurance so primary care.
Specialty care hormone therapy and gender affirming surgeries are covered in California again we spoke a little bit earlier how that varies state by state covered again does not equal free patience are responsible for some costs I think a myth out there is that oh it's covered I won't have to pay anything.
That's not necessarily true it really depends on the kind of insurance you have in the plan so it's really again important to know what your out-of-pocket expenses are going to be what's your deductible all of that is gonna be really important for you as an individual and accessing gender for main care generally most insurances do not.
Cover facial feminine struct of surgery and voice surgery or therapy they're deemed as cosmetic that's not our opinion are our pain here at the gender help program and I think for most trans health programs is that these are all medically necessary they are life-saving but that's currently where we're at right now so there is an appeals process.
And that you can pursue as somebody who has health insurance and again it's really important for you to kind of have a network of folks who can really go to bat for you and provide that advocacy to your insurance generally that's you know primary care physician specialty care physicians and mental health professionals so getting into a little.
Bit of what the letters look like so for top surgery right or chest reconstructive surgery whether that's double mastectomy or breast augmentation generally you need one letter from either a primary care doctor or mental health professional again each plan varies so to really look at your trans health policy and figure out what it is.
That they're looking for and also in the letter which is outlined in the standards of care document with through W path it outlines what certain points need to be in the letter in order for insurance to cover it two letters of our statements of medical necessity are needed for bottom surgery or any kind of below-the-belt surgery so we're talking.
About orchiectomy x' hysterectomies vaginoplasty phalloplasty anything that is below the belt will require two letters and again there is some variance on whether a doctor can write that letter or it needs to be a mental health professional so it's me really important for you to kind of figure that out and then also to it's important to note that.
Some programs trans health programs or doctors do a letter for starting hormone replacement therapy or HRT others operate from an informed consent model so that'll also be something that you will need to do some research on as well so pediatric patients so health insurance in California does cover.
Gender firming care for pediatric patients so folks that are less than 18 years old each patient and caregiver system is unique and ideally pediatric care for trans or gender diverse you really should involve the care system whatever it is that it looks like and it's also important to note that in the state of California any kind of medical.
Or surgical intervention needs parental or caregiver approval so that's law so it's going to be really important for you if you're a youth looking for this care to really understand that so again I get a lot of questions about is my insurance contracted with UCLA health because folks regardless if you're trans or.
Gender diverse identified want to come to UCLA health so UCLA health is contracted with a variety of HMO PPO medical plans and medicare you can verify with your insurance directly if UCLA health or the specific doctor is in network or you can go to these resources here you can call 1-800 UCLA MD 1 or visit us online as well to figure out if.
Your insurance this is accepted here at UCLA health and again you can also call your insurance directly and mention which doctor or healthcare system you're looking to visit so now some important insurance considerations to keep in mind as you're kind of navigating insurance landscapes are going out which plan is best for you research is going to be.
Very important you we really want you to make sure that it's within your means to pay for the insurance that you can pay for so that's gonna be like kind of the basis we really want to make sure that you're accessing health insurance that you can afford and then also when you're accessing health insurance you can ask if they have a specific transgender.
Health policy and again this is often informed by W and in order to figure that out you can ask any kind of insurance rep that or you can look at and request your health insurance plan booklet so in there it'll kind of go over again what that policy looks like what it is that they require so it's kind of like a formal document.
So it's gonna be really important for you to take that into consideration again Medicaid state based health insurance varies state by state and then also one thing I also want to underscore is that due to the Affordable Care Act you are able to stay on your parents or caregivers insurance until the age of 26 so if you do find yourself in that.
Category you whoever is the policyholder will be notified when you use that inch when you access that insurance but what you can do is request that all of your bills and your documentation be kept confidential and sent to you personally but at some level whoever is the policyholder of the plan will be notified when you use it right so I say.
This just because I don't want to create any situation or any tension that could find folks homeless or without resources so it's really important to keep that in mind but also that you do have certain protections so really call your insurance and ask that you know certain protections are put in place to keep your privacy other important insurance.
Considerations is that a college student health some college student health plans offer really great in comprehensive gender affirming care so if college is on your to-do list if it's something that you're looking for that's also something to look at and then also certain employers are very proud of their inclusive transgender health.
Policies so if you're looking for jobs you know you can also look to that as well as to guide you in insurance another important thing to mention is that if your insurance through your employer is self-funded and self-funded is a way for the company to kind of save some money there can be exclusions to gender affirming care but you can ask.
Your HR to remove them and if they won't or if they say that they're not going to there are legal options that you can pursue but just know that again if you're if the health insurance offered through your employer is self-funded there might be some navigating that you have to do to get the gender framing care that you deserve.
Insurance denial appeals they're always very unfortunate but there's also a very sometimes necessary procedure that you'll have to go through so again in W path it's stated that the age of 18 is the age of legal majority meaning that's when insurance will cover for like Top surgery or bottom surgery but we have seen folks who are less than 18 15 16 17.
Who have access top surgery or double mastectomy 's but they did have to go through that appeals process right so after your consult with a surgeon the surgeon will then send off the authorization to get approved for surgery if you are under the age of 18 there is a chance that it will be kicked back and said that it is denied but.
Again that's just seen as a little bit of a speed bump there's a process for you to appeal that decision and again it's that kind of underscores really having a robust and well-rounded care team because in your primary care doctor your mental health provider can go to bat for you and challenge that appeal from the medical and mental health.
Professional stance and hopefully get that overturned again we have seen trans mask identified folk who are under the age of 18 get that care but it does kind of vary again based on your insurance for folks who cannot apply for health insurance or like medical in the state of California because of their immigration status.
There are ways for you to get that gender affirming care so my health LA is specifically for folks who are undocumented so that's a really great resource for folks to know about and then also some Planned Parenthood locations do offer sliding scale costs and do offer hormone therapy so that's also something that you can use as well.
And then again I know it's a little bit dismal to look at the state or the the map of the United States and see that most states really don't provide trans inclusive health care but I wouldn't say that you're hopeless right really kind of acts see local lgbtq+ centers or the resources that I will talk about later.
Or even local health systems and helping navigate that so I don't want you to you know lose hope based on the state that you live you know there are resources out there for you to look at again so if you ever need to approach insurance if you need to go to a self-funded plan these are some tools that you can use to kind of challenge that decision and.
Hopefully get it overturned and again if you need the appeals again the well-rounded team is going to be super important but appeal appeal appeal I would encourage you to do that it does take time it is a lot of energy but unfortunately that's kind of the state of health care right now so now Diggins to some resources so we.
Are not the only folks providing this care we are not the only organization doing these kind of webinars or videos there are other online based resources that you can look at transcend legal the National Center for transgender equality the transgender Law Center these are all web-based resources that look at policy state-by-state again I mentioned the.
Human Rights Campaign at the beginning they also have stuff you can look at as well they also have state-by-state breakdowns and specific insurance plans and what those benefits look like so if you find yourself outside of California you can look at these resources to get a better understanding of what it looks like or trans health care looks like in.
Your state again we mentioned letters letters being kind of a a speed bump though in some regard but also a need to checks and balances for gender forming care and they have the gender affirming letter access project or Gallup so these are mental health providers who have pretty much said that they are open to writing the letters required these are.
Mental health providers who are open to writing the letters required for surgery and it does go state-by-state so I would encourage you to look at that to kind of see who's in your neighborhood who's in your area and how you can access those letters additional resources can be found on our UCLA gender health program website so.
If you go to our website go to the resources tab there's also a bunch of other resources as well you're free to look at all right so now I think it's time for some questions and I think we have some thank you okay so the first question is what does inform consent model mean that's a good question I didn't cover that in my presentation.
Informed consent model means that any provider will kind of go over the cons and pros of choosing whether or not to go down a certain route or a certain intervention so whether that be surgical or hormone therapy and if they feel that you have the capacity to make an informed decision they will go ahead and give you a document for you to sign and.
Then care can proceed so again it does vary by program some programs do require a letter from a mental health professional or primary care doctor others do operate from an informed consent model which is pretty much just a general conversation talking about your health your care goals and then if everything checks out and that provider.
Feels comfortable they are able to make that informed decision they will go ahead and prescribe you the treatment that you're looking for the second question is how do I know if my health insurance plan is self funded or insured another great question generally you can go to your HR department and ask for that and generally in the plan booklet.
That I mentioned earlier it'll also say kind of on the front page whether or not it is or is not self-funded but generally if you go through HR your benefits coordinator at your employer you'll be able to figure that out pretty quickly who can write these letters or statements of medical necessity again another really great.
Question so these are primary care doctors anybody that's in your care team whether that's a mental health provider or like I said a primary care doctor so pretty much anybody with like a medical or mental health background can write these letters and again it will vary based on your insurance plan so to look at your plan book it booklet look at the.
Transgender health policy and sometimes it'll specifically say one letter must be from a mental health professional one must be a primary care doctor so it's going to be really important for you to look at that but generally it is a mental or medical professional another one another the last question that we have is does.
Health insurance cover mental or behavioral health services so most insurances do cover mental or behavioral health services again if that's something that's important for you and accessing your care that's something that you can research again but generally most insurances will have mental health coverage alright so thank.
You so much for your time I really appreciate it if you want any more information you're more than welcome to give us a call contact us this is our contact information I know things are a little hectic right now but I really hope that all of you are staying well you're following CDC guidelines to keep yours yourself as.
Well as yours safe and if you are ever in need of up-to-date fact-based information on kovat 19 or coronavirus please feel free to go to the UCLA health website on kovat 19 other than that stay well everybody take care you