Health Coverage Guide | Self-Funded Plans | National Center for Transgender Equality

Health coverage guide

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Self-Funded Plans

 

What is a self-funded plan?

If you get insurance through your or your parents’ work or school—including if you are a government employee—you may have a self-funded plan. Self-funded plans do not work like other health insurance plans. In these plans, your employer or school uses their own funds to cover your health expenses, instead of paying premiums to an insurance company.

 

Why does it matter whether my plan is self-funded or fully insured?

In a self-funded plan, your employer or school decides what the plan should and should not cover. This is important because if your plan is self-funded and has an exclusion or limitation on coverage for transition-related care, it may be more effective to talk to your employer or school about removing the exclusion, and not to the health insurance company that administers the plan.

Self-funded plans are also regulated by different federal laws than most health insurance plans, and state protections are frequently not applicable to self-funded plans.

 

How do I know whether my plan is self-funded or not?

Employers frequently hire health insurance companies to administer self-funded plans. So you might have a plan card or booklet from BlueCross BlueShield or Cigna, and still have a self-funded plan. This can make it confusing for you to know whether your plan is self-funded or insured.

The most straightforward way to find out whether your employee plan is self-funded or insured is to ask your human resources department. Another way is to try to find the information on your member handbook. For example, your member handbook might explicitly say that your plan is self-funded, or list a health insurance company as a “plan administrator.” 

Watch: How to find out if your plan is self funded (video from Transcend Legal) 

 

How can I tell if my self-funded plan covers transition-related care?

As your first step, you should figure out what your plan says about the treatment you need and about transition-related care in general. To do this, you will need a copy of your member handbook.

Watch: How to find your member handbook and understand your coverage (video from Transcend Legal)

If you get your insurance through school, Campus Pride has a list of some of the school health plans that cover transition-related care.

Some self-funded plans don’t specifically mention transition-related care in their documents. Others might have a specific medical policy that has specific criteria on how to access coverage for care.

Some plans still have exclusions for transition-related care overall or certain types of care—even though those exclusions may be illegal. For example, the plan could limit surgical coverage to people over a certain age, or exclude coverage for particular procedures, like facial feminization surgery.

 

My self-funded plan has an exclusion. What do I do now?

If you have a self-funded plan that has a blanket exclusion of transition-related care or an exclusion of a specific procedure, you will likely need to ask your employer or school to remove the exclusion before applying for coverage. It is your employer or school—and not the health insurance company that administers the plan—who ultimately decides what is and isn’t part of your self-funded health plan (that being said, sometimes speaking to your health plan administrator can also be effective in having the exclusion removed).

Below is a sample letter that you can use to send to your employer or school asking them to remove an exclusion. You will have to fill in the blanks with specific information about your work or school.

Download: Sample letter to send your employer to request they remove an exclusion (.doc)
 

Talking to Employers or School Administrators about Trans Coverage

The law protects you from retaliation for telling your employer or school administrator that they are discriminating against you by having these exclusions. However, we understand that there can be real concerns about disclosing your transgender status and about retaliation.

There are steps you can take to protect your privacy and yourself in these conversations. Resources from the Human Rights Campaign and the Transgender Law Center can be helpful for you to think through the best way to approach your employer or school, identify allies in your company or campus who can support you (including, for example employee or student unions), and protect your health privacy rights under the Health Insurance Portability and Accountability Act (HIPAA). You can also check out Campus Pride’s resources on student advocacy in university campuses.
 

 

My self-funded plan does not have an explicit exclusion for transition-related care. How should I go about getting coverage for transition-related care?

We recommend that you apply for preauthorization (sometimes called prior authorization). That means submitting a claim to the health plan administration asking them to approve coverage before you have your procedure.

Even though it is not a final guarantee of coverage, preauthorization can help you and your health care providers know whether your procedure could be covered.

It is common for plans to require preauthorization for surgeries or specific medications, including those that are transition related. Not asking for preauthorization in these cases could result in an automatic denial later on.

You can find instructions for applying for preauthorization in your plan documents or by calling your human resources department or health plan administrator. Remember to always consult your plan documents to see any specific criteria you might need to meet in order to qualify for coverage for a particular treatment.

Below you will find a sample letter you can send to apply for preauthorization. Remember to fill out this template with your specific information.

Download: Template for writing your health plan adminstrator to get transition care preauthorized (.doc)

In addition to this letter, you will need to send a letter from your doctor or other health care provider explaining why the procedure or medication is medically necessary for you. You can refer your health care provider to this guide to write their letter. You should always discuss with your health care provider what your plan requires for preauthorization and what you (or the doctor) need to submit to them.

 

What should I do if I get a denial?

We strongly recommend that you reach out to a lawyer or a clinic for assistance with insurance appeals, including in appealing denials of preauthorization (you can find a list of resources here). You should always refer to your plan booklet or ask your human resources department for information in writing about your options to appeal denials of claims or preauthorization requests. For example, if you are a federal employee, you can dispute the claim with the Office of Personnel Management, in addition to the plan carrier. 

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