Insurance coverage for facial feminization surgery can be an intricate topic. Each state and insurance provider has different policies regarding coverage.
First step to finding an in-network surgeon should be contacting your insurance carrier and reviewing their Certificate of Coverage document.
1. Medicare
One major determining factor for transgender surgery affordability for patients is whether their insurance will cover its costs. While some opt to pay cash installments for facial feminization procedures, others rely on their insurance coverage as it helps cover some or all of these treatments. Unfortunately, coverage varies greatly between insurers so it can be hard to know exactly how much each plan covers or owes out-of-pocket.
Medicare is a government-run health care program for older adults that offers a range of medical services and benefits, including gender affirming treatments when they meet certain criteria. Medicare does have rules regarding their determination before covering them though.
Recent surveys revealed that most states cover genital surgery and some form of facial surgery to treat gender dysphoria; however, only California provided specific coverage of facial feminization procedures. LA Care’s website features their policy that covers this form of gender affirming surgery when necessary to treat gender dysphoria or reconstructive procedures are considered reconstructive in nature.
Many transgender and non-binary people see gender affirming surgery as their only viable means to achieve their desired results and reduce risks associated with hormone therapy alone. If they meet Medicare eligibility requirements, their surgeon will submit a request for preauthorization from Medicare through letters of support following WPATHs Standards of Care.
On average, it took six months from initial consultation with a facial feminization surgeon until receiving final insurance authorization decision, an amounting both time and money for individuals. Of those whose procedure was approved without additional steps or appeals (Group A), with others going through standard approval processes similar to other reconstructive surgeries (Group B).
2. Medi-Cal
Insurance policies typically cover some portion of the total cost for FFS surgery; the exact percentage depends on both your policy and surgeon’s individual determination of what procedures are medically necessary.
Medi-Cal will only cover gender affirming surgery services when it is deemed “medically necessary,” which depends on factors including anatomic areas involved with your gender dysphoria, as well as your surgeon’s recommendation. Therefore, it’s crucial that you discuss all available options with your surgeon prior to making a decision that would best help achieve your goals.
Patient were classified into three groups according to their insurance authorization process: Group A included those covered by public coverage like Medi-Cal and Medicare which allow gender affirming surgeries without needing prior approval; Group B consisted of private policies such as HMOs or PPO plans which required prior authorization before gender affirming procedures could take place; while Group C consisted of those not subject to state oversight – for instance ERISA self-insured employer plans which fall under federal jurisdiction.
Group A and Group B patients needed an average of 5.1 +/- 0.7 months between initial consultation and presurgical authorization approval, due largely to additional administrative and attending craniofacial surgeon time spent navigating multi-level appeals and independent medical review (IMR) requests. This time difference could have been mitigated with more comprehensive patient screening before surgery was scheduled for Group C patients.
Reaching out to your primary care physician is recommended when seeking to find out which surgeons are in-network with your existing insurance policy, although many insurance providers also maintain lists online of surgeons that belong to their coverage plans.
Gender dysphoria can be an emotionally and psychologically challenging issue to address alone, so we recommend speaking to a physician familiar with gender affirming surgical procedures and those covered by your insurance plan. If there’s any risk that your desired facial feminization procedures won’t be covered initially by insurance, plan for denial; in most cases you can appeal their decision within certain time frames.
3. Employer-Based Insurance
Facial feminization surgery may not be required of every transgender individual, but it may be essential to the mental wellbeing of many who transition from male to female. Without it, gender affirmation and accepting oneself as female are difficult tasks; social acceptance often correlates directly with how feminine one’s body appears.
Employer-based health insurance policies typically cover facial feminization surgery. Although the process may take some time and effort, gaining coverage could ultimately bring you relief and treatment you desire.
Step one of this process should involve finding surgeons in-network with your insurance policy. Your primary care doctor or the insurance company’s website may be able to recommend some, or once you’ve decided on one contact them and ask for an appointment for preauthorization.
At your initial consultation, the surgeon will assess your face and recommend solutions that will best help you reach the look that you desire. They will then submit this information for approval by your insurer; how long it takes before they issue their final verdict will depend on each company.
Though timings will differ, you should expect to spend considerable time and energy trying to secure facial feminization surgery through insurance. This includes all administrative and physician costs related to trying to secure authorization; on average this takes over six months; this process often exceeds reported estimates and could reduce patient accessibility significantly.
When your insurance company denies services, make sure to receive this denial in writing and understand why. From there, you may appeal both internally or externally for treatment if required. It may be that they see this procedure as cosmetic rather than medically necessary – if this is the case it would be important to hire an experienced attorney as representation in court proceedings is also key in such a scenario.
4. Private Insurance
FFS can be an integral step on the journey to gender affirmation for MtoF transgender patients. Although hormone therapy can significantly feminize a body, achieving acceptance of female bodies and identities remains challenging without additional support such as FFS. While there are various means by which FFS services may be paid for privately insured companies are most often the source for FFS coverage.
Attaining gender-affirming surgery through private insurance coverage can be challenging. To make things simpler, seek out a surgeon with experience working with private insurers to get procedures pre-authorized – this will make moving forward much simpler once approved. In your consultation you can discuss multiple procedures needed for achieving your desired look; your surgeon should have a good sense of which are likely covered.
When trying to secure insurance for FGCS it is essential to remember that the process can take considerable time and energy. Working with a physician who understands these complex issues will provide support and guidance during every stage of this journey.
As part of being aware of gender-based laws in your state, it is also crucial that you are knowledgeable of its laws related to discrimination based on gender. Most states contain protections which prohibit categorically denying gender-affirming surgeries such as genital reconstructive and facial feminization surgery if these are categorically denied in policy terms. If such exclusion clauses exist within policies for procedures considered medically necessary it might be worth trying to advocate on both an internal and external level for them being recognized as medical necessity as soon as possible.
Letters of support from your primary care provider and/or therapist who prescribe your hormones can also help substantiate the case for your FGCS procedure to be considered medically necessary. In addition, having a letter from your surgeon detailing your case and why he or she believes coverage should occur can often prove extremely helpful.
