Dr. Mosser’s Guide: How to get your MTF or FTM top surgery covered by insurance
One of the most stressful questions in the transgender journey is: Will insurance cover my surgery? And even if it does, how much will I have to pay?
Here are some guidelines to help answer these questions (and more!) below. Your first step is to reach out to us for a consultation. We have an Insurance Concierge who works directly with your insurance provider and take you through every step of the insurance approval process until approval is achieved, or until the point where it is clear that you do not have coverage. We provide the Insurance Concierge as a free service to give you the best chance of success.
To help us verify the benefits, we will need the following information from you:
- Full Name
- Date of Birth
- Procedure(s) you are looking to have covered
- A scanned copy of your insurance card (front and back)
- Your best contact number (where we can also leave a message)
Once we have your information we will contact the insurance company and get in touch with you as soon as we hear from them. When we contact you, we’ll present one of the following scenarios:
Scenario A: Your insurance carrier does not cover the cost of FTM or MTF top surgery.
What You Can Do:
- Pay out-of-pocket for the procedure.
- Finance your procedure with CareCredit. It works just like a credit card but is exclusive to healthcare services. You may use your card multiple times for different procedures and products and still enjoy low monthly payments.
- Finance your procedure with a loan. There are several lenders who offer loans specifically for plastic surgery procedures.
And don’t worry, we’ll help you explore these two options.
Although in general California law prohibits insurance companies from denying transgender benefits, there are two exceptions:
- If the policy is a large group that is ‘Self-Funded’, meaning the employer assumes the direct risk for payment of claims or benefits (not the insurance company). These policies are not required by law to have transgender benefits.
- If the employer’s corporate office is in a state other than California, the health benefit policy falls under the laws of the state where the corporate office is located.
Scenario B: Your health insurance covers FTM Top Surgery.
This scenario can be further broken down into two possibilities:
Possibility #1: Your insurance is with Anthem Blue Cross, Blue Shield or Brown & Toland. Our practice has agreements with these providers so your approval process should be smooth and straightforward.
What we will need from you for authorization approval:
- a letter from a mental health provider stating that you meet WPATH guidelines for surgery
- notes from your consultation with Dr. Mosser which we will have ready 1-2 days after your consultation
- referral to Dr. Mosser from your Primary Care Doctor or PCP (if you have either an HMO or are getting your insurance through a school)
There may be additional requirements based on individual circumstances.
Once we receive the necessary documents, we’ll start the request for authorization right away! It takes a week or two to receive a response from the providers with whom we have an agreement.
Possibility #2: You have insurance coverage but Dr. Mosser does not have an agreement with these providers.
There are a couple of ways to have your MTF or FTM surgery covered even if Dr. Mosser doesn’t have an established agreement with your company. These include:
- Our office can obtain a single-case LOA (Letter of Agreement) with your provider. This is usually a one-time contract between Dr. Mosser and your insurance for this procedure, just for you.
Our team has experience securing approvals for Dr. Mosser to work with the following insurance providers:
- Aetna (Student Services only)
- Anthem (National and California)
- Brown & Toland HMO
- Health Net
- Blue Shield
- Aetna National
- Hills Physicians (HMO)
- Excellus (Blue Cross/Blue Shield of New York)
- United Health Care
In short, if anyone can get an LOA, we can.
- In the rare cases when an LOA cannot be obtained, you will then pay up front and then we continue to try to get reimbursement for you after surgery. In this case, you would receive reimbursement from our insurance plan later (minus a 6 % administration fee).
Your insurance would treat this case as ‘out-of-network’. It is still beneficial to go through the authorization process because this can greatly reduce your hospital expenses and usually your insurance will pay for a portion of the surgery. For instance, it’s possible for you to have 9010 arrangement in terms of in-network coverage pay while 70-30 for out of network.
What If I have transgender benefits on my policy but they don’t have doctors in their network to perform transgender surgery?
Your insurance provider is required by law to refer you to a surgeon who can perform the procedure.
Obtaining approval may look like an overwhelming process. However, with our experienced staff to help, you’ll be able to maximize your insurance benefits without the hassle and stress.
And, just to boil this down to bite-size, here is a summary of most of this information as a flowchart, also downloadable as a PDF here: