‘Dignity and Self-Determination’: A Guide to Health Insurance for LGBTQ+ Ohioans

Premium

“Your premium is the set amount of money that you pay to your health insurance company every month for your health insurance plan. It either gets sucked out of your paycheck or you have to pay it to somebody else.”

Co-Pay

“When you go to the emergency room or you go to see a physical therapist or a specialist, most people have something called a co-pay. The co-pay is the extra money that you pay in addition to your health insurance to pay for your visit.

Most people have health insurance that covers primary care appointments without a co-pay, or with a very low co-pay, because most insurance companies want you to have a primary care doctor. 

Sometimes, the way insurance companies determine co-pays can get a little ridiculous. For example, you might not have a co-pay to see your primary care doctor for preventative stuff, but you might have to pay if you’re getting something treated. All insurance plans have weird rules around this, so it’s important to look at your specific plan so see exactly what the co-pays are. 

Usually, you have to pay additional money to go see a specialist doctor because it costs more to see them in general and your health insurance has to pay out more. That’s just for a regular visit [with a specialist] — talking to the doctor, getting the exam and then making a plan. Then, people also have to access things like imaging testing, physical therapy and occupational therapy, which could also have co-pays.”

Deductible

“The deductible is the amount of money you have to pay out of pocket before the health insurance starts kicking money in and paying for your care. Usually, the less you pay for the premium, the higher the deductible is. They’re either going to charge you on the front end or the back end.

Most deductibles don’t pay anything until you’ve paid a certain amount of money. With some deductibles, you have to pay by percentage until you’ve reached that set amount of money, then they pay for everything else after that.

If you know you’re planning have [an expensive gender-affirming procedure] — or if, unfortunately, you’ve ended up in a year with a bunch of unexpected health insurance expenses — it’s probably a good idea to get any other procedures like scopes, images or screenings done within the course of that same year so you’re paying as little out-of-pocket as possible.”

 Co-Insurance

“Co-insurance is the percentage of the cost of the medical care that you have to pay after you reach your deductible. For a lot of people, their insurance pays for everything once they hit their deductible. But sometimes, after you meet your deductible, insurance will still only pay for a certain percentage. 

For example, insurance might pay 90% of the cost after meeting your deductible while you pay 10%. It’s important to look into your health insurance policy to see exactly what’s covered, so you can do your best to budget.”

Out-of-Pocket Maximum

An out of pocket maximum is the most amount of money you will have to have to pay for health care covered under your plan in one year. Once you reach that limit, the company will cover the total allowed amount for all in-network care.

“The Affordable Care Act (ACA) changed out-of-pocket maximums so they’re much more flexible than they once were. Often, it’s a pretty substantial amount of money, but it’s also important to check when you’re looking into what will work best for you.”

In-Network and Out-of-Network

“Every insurance company has a network of healthcare providers that contract with the company to provide negotiated prices. When a provider is “in-network,” they have agreed to participate in the insurer’s healthcare plans. When a provider is “out-of-network,” their services are not included in your insurance company’s plans, and will likely cost far more to access.

Generally, patients are able to see in-network providers with an inexpensive co-pay. But according to an explainer published by healthinsurnace.org, healthcare services provided by out-of-network doctors or hospitals are likely not covered, or covered only partially, depending on the specific insurance plan.

Generally, it is a good idea to seek care from in-network providers covered by your health insurance plan. However, out-of-network providers can play an important role in healthcare more specific to LGBTQ+ patients — like certain gender affirming procedures and mental health services.”

Reimbursement

If you see an out-of-network provider — or a provider that doesn’t accept any type of insurance — your insurance company may cover all or part of the cost of services from out-of-network providers via a process called reimbursement.

“I only accept one insurance that I’m in-network with,” said Emerson Douglas, a clinical social worker, a licensed psychotherapist and an out queer and trans man. “Otherwise, I don’t accept insurance.”

“The insurance company gets to decide how much they pay professionals,” Douglas explained. “We contract with them, they give us a contracted rate and we can’t negotiate that. Some insurance companies don’t reimburse clinicians well, so I would have to see close to 40 clients every week to make a living. I choose to only accept one insurance that pays me well. That way, I can help people who have some insurance without overloading my caseload.”

“With reimbursement, clients pay my fee up front at the time of the session. Then, I give them documentation called a superbill, which explains their diagnosis, gives all the details about my practice, tax ID, license number, procedure code, the date that we met and the amount that person paid for that service. 

Clients can submit the superbill, along with a form, to their insurance. Depending on your out-of-network benefits, the insurance company then reimburses you a certain percentage of what you’ve already paid out-of-pocket.”

It is important to check the out-of-network benefits outlined in your specific healthcare plan, because you may be required to meet an out-of-network deductible before your insurance company will begin reimbursing you. Some insurance plans have a lower out-of-network deductible — for example, $500.

Douglas also recommends using an app called Reimbursify that works with insurance companies to submit for reimbursement. You upload your superbill to the app, then Reimbursify interacts with the insurance company, functioning as the middle man. The app charges a small fee per submission.

The Affordable Care Act (ACA)

The Patient Protection and Affordable Care Act (ACA), sometimes called “Obamacare,” is a piece of comprehensive healthcare legislation passed in 2010.

“The Affordable Care Act (ACA) also requires people to have some type of insurance, so there are plans available on Marketplace, which is a whole federally funded program where people can look for a healthcare plan that works for them that they can actually afford on healthcare.gov,” Mintz said.

“The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level (FPL),” according to documents released by the Department of Health and Human Services. In Ohio, the law also allowed for the expansion of the state’s Medicaid program to cover all adults with income below 138% of the Federal Poverty Level.

Open Enrollment

“Most insurance has an open enrollment period, which is the delineated time period when you can enroll. It’s usually around November for pretty much all employers and Medicare and Medicaid.

If something happens that’s an emergency scenario or if there is some significant and substantial change in your life — you get married, get a new job — then people can return to the Marketplace. Generally, switching plans [outside of the open enrollment window] is difficult.”

What is the Health Insurance Marketplace and HealthCare.Gov?

The Health Insurance Marketplace/HealthCare.Gov is a government-funded platform that allows you to shop for health insurance plans from different health insurance companies at different rates. The program also functions as an enrollment service, allowing you to enroll directly in health insurance plans during the Marketplace open enrollment period.

The Marketplace utilizes a system of filters to help you find the type of health insurance plan that best fits your needs — whether that’s a lower premium paired with a higher deductible or a plan that covers a specific medication or healthcare provider you’d like to see or continue seeing in the future.

What is public health insurance?

“Medicare and Medicaid are the two big public health insurance programs. 

Everybody over the age of 65 is eligible for Medicare. There are also a couple other conditions that qualify a person for Medicare, like complex disabilities and kidney failure and needing dialysis. But generally, if you’re over 65, Medicare is the public program that insures you. 

People that are eligible for Medicaid — the other major government-operated public insurance program — meet conditions based on federal poverty guidelines, which are ridiculously low. 

Thankfully, in Ohio, the Governor used the expansion of Medicaid in the Affordable Care Act (ACA) to include people whose incomes are some multiple of the federal poverty guidelines. That means a huge number of people are eligible for Medicaid that wouldn’t have been otherwise — and that’s a good thing! 

Medicaid is funded by each state via the federal government, so every state has a different Medicaid program. We have expansion of Medicaid here in Ohio, but it’s not in every state across the country. Medicaid is open enrollment, so you can apply for coverage during a specific window of time.”

What is private health insurance?

“Private insurance companies are the insurance programs that people get through their jobs, and these can vary massively in terms of what they cover and how they work,” Mintz said. “There’s also hospital or clinic-based insurance, where hospital systems offer specific insurance products that allow you to see doctors that are in their network of care. For everything else, you have to pay out of pocket.”

Employer Benefits

“If you receive health insurance through your employer, it’s important to look into the specifics of your plan. If you’ve never done this before, I would write down each thing you need: medications, specialists appointments, regular therapist appointments.

As you’re looking at plans — including looking at the plan from your employer — check what each specific thing will cost. I’ve had patients get health insurance through their employer, then go get routine labs and get hit with some part of their deductible thinking it was supposed to be paid for. 

It’s really important to do your best to try and think about this stuff before it happens rather than after. Specifically in our communities, it’s important to check if there are coverage exclusions around things.

Most workplaces offer either flexible spending accounts or health savings accounts. Usually, during an open enrollment period, you can choose to have some amount of money taken out of your check, tax free, to use to pay for healthcare and to pay for those uncompensated expenses. 

Different jobs have different policies about how it all works and what is covered, so you’ll need to look into what a flexible spending account covers. Does it only cover particular things? Do I need a letter from my doctor confirming [something I purchased] was a health care expense? There are different ways this type of health insurance is organized.”

Healthcare Management Account (HMO)

“A Healthcare Management Account (HMO) is a healthcare management plan, which means that the health insurance company says a certain group of doctors and clinicians are responsible for the entirety of your healthcare. 

On the hospital side of things, via the Affordable Care Act, there are similar programs where medical groups sign up to be paid instead of to be paid at once, instead of being paid for each thing individually. The medical providers are getting a chunk of money to take care of you and then they provide your care for the year.

Usually, HMOs restrict the number of people that you can see. If you think about it, none of this is for the benefit of the patient. The way most organizations and institutions are set up, it relies on a primary care doctor to act as a kind of quarterback for everything else. 

Usually, people can decide who they want as a primary care doctor, but often there are [stipulations]. You get a primary care doctor, then they can get you a referral if you need a referral somewhere else.”

Preferred Provider Organization (PPO)

“A Preferred Provider Organization (PPO) is a network where a certain group of healthcare providers have signed up to be accessible to provide your care. Usually, a PPO is way more flexible. 

A lot of times, an HMO, will be within one healthcare system or one environment, a PPO covers a bit more, covers more doctors and often — more so than an HMO — allows people to just access services, specialists and support on their own. 

If somebody needs a rheumatologist, they can call a rheumatologist, rather than needing a referral. [However,] in a lot of cases for a lot of places those differences have just been erased or mushed together. The important thing is to look at the specifics of the plan, especially for surgical planning.”

Does your plan cover gender-affirming healthcare?

In order for gender affirming surgery to be something that your insurance covers, first you need to find out if your employer’s plan, your specific Marketplace plan or your Medicaid plan covers gender affirming surgery. 

Public insurance programs cannot discrimination against transgender and LGBTQ+ people. Private insurance companies, however, may still find ways to avoid covering gender affirming medications, therapies or procedures for transgender patients. 

There might be some policies still today that completely exclude surgery. Unfortunately, private companies can do that. Medicaid is not allowed to do that, but still they sometimes go out of their way to deny surgeries.

You can confirm that your specific plan has coverage and make sure there is not a specific exclusion [for gender affirming care]. If there’s an exclusion, there are ways to appeal it, but it’s pretty difficult.

You can look at that company’s specific medical policy, which is the criteria they use after they confirm that your plan covers it. The insurance company’s medical policy generally aligns with WPATH standards. The World Professional Association of Transgender Health (WPATH) has specific standards for gender affirming chest surgery: a written assessment from at least one qualified behavioral health professional with competencies. Then it lists all the documents that an individual would need. 

Sometimes, you’ll have to click through a document to acknowledge that this [information] might change sometime in the future. Then, you can search. They have tons and tons of medical policies listed for approving therapy, gender affirming surgeries — all that stuff.”

“To approve the surgery, there’s documentation needed both from a medical professional and a mental health professional. Those go hand-in-hand, but because the surgeon is the one actually submitting it to insurance, that’s where you want to start.

The insurance company will require you to meet a certain set of criteria in order to approve gender affirming surgery, or any type of gender affirming procedure — starting hormones or a therapy session or a mental health assessment

With gender affirming surgeries, usually there’s clinical criteria from insurance. You have to meet certain requirements: being over 18, having a diagnosis of gender dysphoria that has been persistent. 

Sometimes, the clinical criteria you need to meet for your insurance to get your procedure approved might actually be different than the surgeon’s clinical criteria for performing the surgery.

I write letters for people with a specific emphasis on getting that exact wording from the insurance policy, so there’s no question that this person meets these criteria. Unfortunately, a lot of therapists don’t do that. Instead, they have a very general template and that often results in letters getting [sent back from the insurance company], saying ‘You didn’t use the correct language.’”

“There is often a difference between what the health insurance company says they cover and then what the health insurance company makes easy to actually get covered.

Particularly in the surgical realm, the person who’s going to do the authorizations and the documents for any kind of gender affirming surgery is the office of that surgeon — for everything: hair removal, facial feminization, whatever it is.”

“At MetroHealth, we have five plastic surgeons — all of whom do some top surgery. Everyone does mastectomies, but only one of us does facial feminization surgery. Only two of us do augmentations and only 1.5 of us do any kind of bottom surgery. 

A lot of times patients will get a referral and they’ll just get the phone number to call. There’s this triage that happens and it’s not always the right person who answers the phone.

All of these people work together every day to do all of the insurance pre-determination and collection of all the things that we have to submit in order to get there and then the scheduling process afterwards, but they don’t all work with all the surgeons. There is a point of differentiation that happens, at least for us. I expect that that’s probably true everywhere.

Not all surgeons have the same approach to getting to the office. Some of us don’t care if you meet all the requirements you need [to schedule your surgery] when we see you.

I would rather have an upfront conversation with the patient so that I know what their goals are and what we’re trying to do. That way, we know what things we need to do in order to get there before I ask them to jump through all these hoops and get letters of support or buy a garment for after surgery.

Others in my office say that they don’t want the patient to feel like they get to the office, but then they can’t have surgery yet, so they ask for them to get a little bit further along in the process before they have their first consult in-person.

Once the patient gets to my office, I try to figure out where we are in that process, and sometimes they already know and they are very familiar with what their specific insurance provider requires. Sometimes, they’ve already identified a letter writer or two, depending on what we’re talking about.”

Covering PreP and HIV Care

PrEP (Pre-Exposure Prophylaxis) is an HIV prevention medication that is extremely effective in preventing HIV infection — both via sex and via intravenous drug use. When taken as directed, PrEP can lower a person’s risk of contracting HIV by 99%.

According to the Centers for Disease Control (CDC), most state Medicaid plans cover PrEP. Without insurance, the drug can cost patients between $22,000 and $33,000 per year out-of-pocket. Because

PrEP is so expensive, there are several different financial assistance options, including via the Ohio Department of Health.

Drug companies themselves also offer financial assistance specifically around PrEP. Gilead — a major manufacturer of the drug — offers coupons for the medication via their Advancing Access co-pay assistance program. Often, programs like Gilead’s provide patients with a pre-paid co-pay card that can be used to pay for the prescription directly.

The program also offers assistance in completing the prior authorization process and navigating insurance claims denials and re-submissions.

Insurance Denials and Appeals

“Predetermination is when the insurance company agrees that the procedure we’re doing is medically necessary. We put the correct diagnosis codes, which usually include gender dysphoria in an adult, and then whatever procedure codes are anticipated. Generally, procedure codes are available if you search them via Google.

My office will check that, too. Then, they will actually call the insurance company and make sure that they understand what the codes are. For example, if I submit a code that says mastectomy, a lot of insurance companies will say no pre-approval is required. We have to explain that this is not a mastectomy for a cisgender female with cancer. This is a mastectomy for gender affirmation. 

My office has to actually call every single one of those and get to a person to confirm those benefits to make sure that there is not an issue later with coverage and the patient gets a bill. They spend a lot of hours every day on the phone with insurance companies to confirm that the patient has benefits for gender affirming surgery, specifically with those codes and that diagnosis. That is the most common thing that causes a problem later.”

“When we submit for predetermination, we send all of the necessary paperwork to meet all of the requirements that are listed by the insurance company. Theoretically, they have a certain number of weeks to make a decision and respond to that. When they do, most insurance companies send a letter on paper in the mail.

If they deny the procedure, we typically only have about 10 days to do what’s called a peer-to-peer. When the insurance company denies a gender-affirming procedure I’m able to do that peer-to-peer on behalf of the patient. As the surgeon who saw the patient in the office and made recommendations and came to a plan with the patient, I get to talk with somebody designated by the insurance company about why they’re incorrect.

If it’s denied, because [the surgery, procedure or care] wasn’t included in the prior authorization, then I write another letter for that client. The other part of the appeal process is mostly through the surgeon’s office. I usually tell people to first reach out to their surgeon’s office, send me the letter confirming it was denied and we’ll figure out the next step.”

Getting Financial Assistance

“Most people cannot afford the deductibles and coinsurance fees anyway. If you get a bill that you can’t afford, contact the hospital. Contact their financial assistance department and talk to someone. Don’t let the terror of seeing that ridiculous bill just shut you down.

If people don’t qualify for Medicaid, can’t afford a Marketplace plan or are in some other way ineligible for funding, but still can’t really afford health care, it can be useful to go to the financial assistance programs of whatever hospital system you’re working with.”

If you’re not eligible for public insurance — like patients who hold citizenship in countries other than the United States, or patients who are living in the United States without official immigration documents — Vargas and other LGBTQ+ healthcare providers said there are still ways to obtain financial assistance:

“Many major hospitals and Pride networks offer surgery scholarships. If you’re in a situation where you don’t have access to coverage — or if your plan doesn’t provide those benefits even though you do have coverage — there are resources to help you.” 🔥