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Transgender Health Insurance Resources

Insurance Information For Gender Reassignment & Transition

Transgender health services are increasing in demand, and many health plans are catching up as indicated by the literature for the insurance companies listed below.

While it may take time and legal action for gender reassignment surgery, hormone therapies and other transgender-related treatments to be covered by more health plans, such services are listed in the Outlines of Coverage for a growing number of carriers. Patients with Employer Coverage may have a better chance of their policy covering a portion of costs, as the employer is able to negotiate with the insurer directly rather than default to the carrier’s guidelines.

The links below direct to a selection of documents from nationwide insurance companies discussing their coverage and exclusions for transgender-related medical care.

UPDATE: Case Study, November 2016

Blue Shield of California Bronze 5550 PPO

As of Nov. 2016, we researched a policy for one of our prospective clients, and confirmed that the Bronze 5550 PPO individual health plan with Blue Shield of California would cover gender reassignment surgery as an in-network procedure.

This great news comes with a checklist of requirements to meet before assuming all of your bills are going to be paid, or even heavily discounted by insurance when you go under the knife.

We confirmed that this policy covers medical billing code CPT 55970 (intersex surgery, male to female) subject to deductible, coinsurance, and the out of pocket maximum. Services will be covered as long as the prescribing physician indicates the surgery is medically necessary, and submits supporting documentation as proof of medical necessity. Additionally, all providers and facilities must be in the plan’s network for optimum savings.

Coverage for services can be denied if all the requested documentation, proper codes, and network requirements are not met. Compelling language from the provider confirming medical necessity is often needed in such instances, in addition to submitting the correct CPT codes when billing insurance.

 

Aetna

Gender Reassignment Surgery: Benefits/Coverage Details

Amerigroup

Gender Reassignment Surgery: Benefits/Coverage Details

Anthem Blue Cross Blue Shield

Gender Reassignment Surgery: Benefits/Coverage Details

Blue Cross Blue Shield of Massachusetts

Transgender Services: Coverage Information

Blue Cross Blue Shield of Michigan

Gender Reassignment Surgery: Benefits/Coverage Details

Blue Cross Blue Shield of North Carolina

Gender Reassignment Surgery: Benefits/Coverage Details

Blue Cross Blue Shield of North Dakota

Treatment of Gender Identity Disorder:  Benefits/Coverage Details

Blue Cross Blue Shield of Rhode Island

Gender Reassignment Surgery: Benefits/Coverage Details

Blue Cross Blue Shield of Tennessee

Gender Reassignment Coverage (see General Surgery, Gender Reassignment)

Blue Cross Blue Shield of Vermont

Gender Reassignment Surgery: Benefits/Coverage Details

Blue Shield of California

Gender Reassignment Surgery: Coverage Information

Care First

Transgender Services: Coverage Information

Cigna

Gender Reassignment Surgery: Benefits/Coverage Details

Emblem Health

Gender Reassignment Surgery: Benefits/Coverage Details

Excellus Blue Cross Blue Shield

Sex Reassignment Surgery: Coverage

Group Health Cooperative

Transgender Services Program

Harvard Pilgrim Health Care

Transgender Services for Fully-Insured Subscribers and Dependents

Health Net

Coverage for “Gender Reassignment Surgery”

HealthPartners

Gender Reassignment Surgery: Benefits/Coverage Details

Highmark

Gender Reassignment Surgery: Benefits/Coverage Details

Humana (Group)

Sex Reassignment Surgery: Employer Coverage Example

HumanaOne and Humana Marketplace (Individual)

On 06/17/2015, Humana Sales Support representative Sheila (reference number 448477) informed our agency that gender reassignment surgery, hormone replacement therapy and other such services would not be covered for on or off exchange major medical plans as they are considered elective.

Independence Blue Cross

Sex Reassignment Surgery (SRS) for Gender Identity Disorder: Benefits/Coverage Details

Medicare

Sex Reassignment Surgery Coverage – 2014 Medicare Policy

UnitedHealthcare

Gender Identity Disorder/Gender Dysphoria Treatment: Benefits/Coverage Details

Wellmark Blue Cross Blue Shield:

Gender Reassignment Surgery: Benefits/Coverage Details

WellPoint – UniCare:

Gender Reassignment Surgery: Benefits/Coverage Details

Medical Billing Codes

CPT
55970Intersex surgery; male to female
55980Intersex surgery; female to male
17380Electrolysis epilation, each 30 minutes
17999Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as permanent hair removal by laster]
19303Mastectomy, simple, complete
19304Mastectomy, subcutaneous
19325Mammoplasty, augmentation; with prosthetic implant
54125Amputation of penis; complete
54520Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach
54660Insertion of testicular prosthesis
54690Laparoscopy, surgical; orchiectomy
55180Scrotoplasty; complicated
56625Vulvectomy, simple; complete
56800Plastic repair of introitus
56805Clitoroplasty for intersex state
57110Vaginectomy, complete removal of vaginal wall;
57291Construction of artificial vagina; without graft
57292Construction of artificial vagina; with graft
57295Revision (including removal) of prosthetic vaginal graft; vaginal approach
57296Revision (including removal) of prosthetic vaginal graft; open abdominal approach
57426Revision (including removal) of prosthetic vaginal graft, laparoscopic approach
58150Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);
58552Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58554Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58570Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less;
58571Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58572Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;
58573Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
ICD-10 Procedure 
0HBV0ZZ-0HBVXZZExcision of breast, bilateral [by approach; includes codes 0HBV0ZZ, 0HBV3ZZ, 0HBV7ZZ, 0HBV8ZZ, 0HBVXZZ]
0HDSXZZExtraction of hair, external approach
0UQG0ZZRepair vagina, open approach
0UQJ0ZZ-0UQJXZZRepair clitoris [by approach; includes codes 0UQJ0ZZ, 0UQJXZZ]
0UT20ZZ-0UT2FZZResection of bilateral ovaries [by approach; includes codes 0UT20ZZ, 0UT24ZZ, 0UT27ZZ, 0UT28ZZ, 0UT2FZZ]
0UT70ZZ-0UT7FZZResection of bilateral fallopian tubes [by approach; includes codes 0UT70ZZ, 0UT74ZZ, 0UT77ZZ, 0UT78ZZ, 0UT7FZZ]
0UT90ZZ-0UT9FZZResection of uterus [by approach; includes codes 0UT90ZZ, 0UT94ZZ, 0UT97ZZ, 0UT98ZZ, 0UT9FZZ]
0UTC0ZZ-0UTC8ZZResection of cervix [by approach; includes codes 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ]
0UTG0ZZ-0UTG8ZZResection of vagina [by approach; includes codes 0UTG0ZZ, 0UTG4ZZ, 0UTG7ZZ, 0UTG8ZZ]
0UTJ0ZZ-0UTJXZZResection of clitoris [by approach; includes codes 0UTJ0ZZ, 0UTJXZZ]
0UTM0ZZ-0UTMXZZResection of vulva [by approach; includes codes 0UTM0ZZ, 0UTMXZZ]
0VRC0JZReplacement of bilateral testes with synthetic substitute, open approach
0VTC0ZZ-0VTC4ZZResection of bilateral testes [by approach; includes codes 0VTC0ZZ, 0VTC4ZZ]
0VTS0ZZ-0VTSXZZResection of penis [by approach; includes codes 0VTS0ZZ, 0VTS4ZZ, 0VTSXZZ]
0VUS07Z-0VUSX7ZSupplement penis with autologous tissue substitute [by approach, includes codes 0VUS07Z, 0VUS47Z, 0VUSX7Z]
0VUS0JZ-0VUSXJZSupplement penis with synthetic substitute [by approach; includes codes 0VUS0JZ, 0VUS4JZ, 0VUSXJZ]
0VUS0KZ-0VUSXKZSupplement penis with nonautologous tissue substitute [by approach; includes codes 0VUS0KZ, 0VUS4KZ, 0VUSXKZ]
0W4M070Creation of vagina in male perineum with autologous tissue substitute, open approach
0W4M0J0Creation of vagina in male perineum with synthetic substitute, open approach
0W4M0K0Creation of vagina in male perineum with nonautologous tissue substitute, open approach
0W4M0Z0Creation of vagina in male perineum, open approach
0W4N071Creation of penis in female perineum with autologous tissue substitute, open approach
0W4N0J1Creation of penis in female perineum with synthetic substitute, open approach
0W4N0K1Creation of penis in female perineum with nonautologous tissue substitute, open approach
0W4N0Z1Creation of penis in female perineum, open approach
  
ICD-10 Diagnosis
F64.0-F64.9Gender identity disorders

 

Please feel free to contact us with any questions or to find out if a health plan near you makes transgender-related services available and affordable.

*Please note that we are not licensed to sell BCBS in Florida.
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