Lucent's Coverage of TS Medical Needs

It's never simple, of course. It took quite a bit of persistence. Lucent's HR organization has beeen wonderful, but the insurance companies are not terribly cooperative. Here's my understanding of how it's handled.

What is covered and how?

• Plan ahead!
  You can only change your benefits once a year, usually in November, effective January 1 of the next year. Be sure your insurance choice is appropriate before you start your transition. If you must fund some of your transition yourself (especially electrolysis) plan in advance and set aside money in your Health Care Reimbursement Account. (See below.)
• Health Plan:
  Choose one of the indemnity plans, not an HMO. Either the POS, PPO, or MEP plans will do, as these are designed by the employer. HMOs are designed by the HMO and you get what the HMO offers. We're not aware of an HMO that doesn't have an exception for transsexual medical needs.

  You must choose a primary care physician on the plan. Choose a GP or other MD whom you are willing to go to for your routine medical needs, and as a first step for your special needs. Be sure your GP is supportive of your transition and that you are open with him/her. You cannot get proper general purpose medical care unless your GP knows what is going on with your body.

• Mental health:
  Lucent has a Mental Health plan administered by Magellan (MBC.) Gender Identity Disorder is fully covered, as long as your counsellor is on the MBC network.

  Of course, in practice, most qualified GID specialists are not on the MBC network. In this case, your options are to ask for an off-network referral, or to cover the costs of the counselling yourself. The details of off-network referrals are unclear, but you have nothing to lose by trying.

  Start by calling the MBC hotline and ask for a referral. They will ask for the nature of the issue (they'll want to look up a tentative diagnosis to find a counsellor qualified in that area) so tell them Gender Identity Disorder.

• Hormones:
  These are fully covered by the Drug Plan. (Do not try to get these covered by the Medical plan, it's a waste of time.) Of course, you'll have to get the perscription first.
• Doctors office visits in support of hormones: These are fully covered as any other doctor's office visit. Be sure you go to a doctor that is experienced with transsexuals, generally either an endocrynologist or a GP with experience in this area. You will generally need a referral from your on-network GP first.
• Electrolysis:
  This is one area that is not considered medical, and is difficult to get covered by insurance. Most electrolygists will not do insurance paperwork. I recommend that you try funding electrolysis with your Health Care Reimbursement Account (HCRA.) This means you pay for it yourself, but in effect it becomes tax deductable.

  You must plan ahead for this, because of the rules of the HCRA. You decide on your annual amount in November to cover the next calendar year. This amount is deducted from your paycheck each month the next year, and you can spend it on any medical need.

  I have not tried this, and I cannot be sure it will work. You will certainly need a receipt, and you may need to show that it is necessary for your mental health. They give, as an example, the cost of a wig needed for the mental health of a cancer patient who loses their hair. You may need a written perscription from a doctor who can write perscriptions (an MD or Psychiatrist.)

  Another approach is to have it done by a dermatologist or a nurse associated with a dermatologist. It still won't be covered by the medical plan, but it should be no problem getting the appropriate paperwork for the HCRA.

  If your dermatologist can document that you have a skin condition that medically requires electrolysis, such as pseudofolliculitis barbae, you may be able to get it covered on the medical plan.

  It is not yet clear if laser treatments are an appropriate and permanent treatment suitable for the transitioning transsexual. Preliminary results suggest that some lasers have temporary results and some other types have more permanent results but only eliminate 30% to 70% of your hairs. If you can have permanent laser treatment done by a dermatologist or their nurses, you may have a less expensive solution that you can certainly apply to your HCRA.

• Sex Reassignment Surgery:
  This is the one that most people focus on when they discuss medical coverage. Of course, there are many procedures involved in SRS and they vary from doctor to doctor, patient to patient, and of course are quite different for M2Fs and F2Ms. Most doctors are not expecting insurance coverage, and will require a cash deposit and advance payment. Most insurance companies are used to denying coverage, using the excuse that it is not "medically necessary" even if there is no exclusion.

  In the case of Lucent employees, it will require persistance and probably require an appeal. Plan well in advance. You will probably encounter resistance and will have to file and refile. Start the process as soon as you have an approximate surgery date, as it may take several months to have the insurance approval.

  It is very important to go through the "pre-certification" process. If you don't pre-cert, you will pay a penalty. If you pre-certify and are approved, you should be able to work with the surgeon to arrange for direct payment by the insurance company. (With a pre-certification, they have written agreement from the insurance company that payment will be made.)

  If your pre-cert is denied by the insurance company, get a written Statement of Benefits showing the reason for denial. Be sure that Lucent HR and that EQUAL! have a copy of the denial, as they can escalate to the insurance company. Follow the advice of HR. They will probably have you appeal using the insurance company procedures.

  If your paperwork is lost by the insurance company (this seems to happen quite a bit) keep re-filing. Record the date, time, and name of the person you speak to, and any committments they make to you, each time you call them. (This is good advice in any case.)

  In theory, it should not be necessary for you to pre-pay and be reimbursed. However, that's what Sharon did. Be prepared to do this.

How did Sharon do it?

Here are some letters she wrote with details: