Equality Transparency And Disclosure
Either way, the inclusion of the transgender services language answers the question for many Anthem Blue Cross customer service representatives as to whether the health plan includes benefits for sex reassignment surgery. We are inching our way toward full disclosure and transparency in the contracts between the insurers and the members so that consumers can finally see what is truly covered in their health plans.
Does Health Insurance Cover Testosterone Therapy
Because testosterone replacement therapy is sometimes considered a new therapy, many patients ask us this question, Does health insurance cover testosterone therapy for me?
Most health insurance providers will cover the majority of the cost of testosterone replacement therapy for men, as long as you can demonstrate a need.
Of course, the amount that your insurance covers varies from provider to provider, and it also varies based on your specific health plan and other variables, like your deductible.
Though we cannot guarantee that your insurance will cover the cost of your testosterone replacement therapy, we can at least help you get the process started with a free consultation or with a simple call to your insurance carrier.
Your health insurance company may have already approved you for testosterone replacement therapy if you have certain medical conditions or diagnoses from a physician. Depending on the insurance company, these conditions can include the following:
- A pituitary tumor
- Klinefelters Syndrome
- Kallmans Syndrome
Other conditions, like having had a prostatectomy, may also preclude you from needing tests to prove low testosterone.
Medicare Part D News Update Why Is Estrogen Replacement Therapy Considered A Potentially High Risk Medication
A basic tenet of recent efforts to reform healthcare is promoting improved quality of care and clinical outcomes while also decreasing overall healthcare costs. A popular strategy to accomplish these goals is to link positive patient care outcomes with increased reimbursement. The Centers for Medicare and Medicaid Services is a major driver of this initiative and has developed a 5-Star Quality Ratings program for its Medicare Advantage and Part D programs. The quality rating system outlines quality rating metrics and corresponding bonus payments. The star rating program was developed as a result of the passage of the Patient protection and Affordable Care Act in March 2010.
One of CMS’ most heavily weighted pharmacy measures is the utilization of potentially High-Risk Medications in the elderly population. Beginning with the 2012 reports CMS began utilizing the Pharmacy Quality Alliance HRM list which was based on the 2012 American Geriatrics Society Updated BEERs Criteria. In communicating to healthcare providers about the use of potentially inappropriate medications in the elderly we often receive feedback about the inclusion of estrogen replacement therapy on these HRM lists. So what is the identified risk of utilizing these medications in the elderly population and what data is it based on?
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Communication Is Key For Smooth Transition
If you are considering using these new health insurance benefits to transition, contact your health plan first and see exactly how they are going to handle the benefits. We know that you will need a diagnosis of gender identity disorder or gender dysphoria. Some plans may want to approve a treatment plan in advance. The communication you and your doctor can have with the insurance company, the fewer hassles you will encounter.
Are Bioidentical Hormones Covered By Insurance For Women
Menopause begins after a woman has her last menstrual cycle. The average age for women entering menopause is 51. Even before that last cycle, menopause changes the hormone balance in a womans body.
Progesterone, estrogen, and even testosterone levels begin to drop. The result is symptoms like mood swings, hot flashes, and thinning of the vaginal lining.
A doctor may prescribe hormone therapy to relieve these symptoms. Hormone therapy also treats some of the long-term effects of menopause like bone loss.
The same coverage guidelines apply here as they do for men. Your policy may cover traditional hormone therapy but not bioidentical hormones. Also, most insurance carriers dont cover testosterone when prescribed for women.
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Prior Authorization/step Therapy Program
Blue Cross and Blue Shield of Illinois’ prior authorization/step therapy program is designed to encourage safe, cost-effective medication use. Most HMO groups and standard products plans include this program. Self-insured and custom fully insured groups offer a variety of these programs to help effectively manage their prescription drug benefit.
Q What Is Gender Transition
A: Gender transition means the process of changing ones outward appearance, including physical sex characteristics, to accord with his or her actual gender identity. Not all individuals who undergo gender transition will opt to complete the full transition with surgery. Members are now eligible for a spectrum of gender transition services along the treatment continuum.
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How Much Does Bioidentical Hormone Replacement Therapy Cost
How much bioidentical hormones cost depends on your insurance coverage. If your insurance covers the prescriptions, youll pay the set copay. Likewise, if your practitioner is a preferred provider, youll pay your regular copay.
If your insurance doesnt cover your prescriptions, you will pay out-of-pocket for them. If your healthcare provider is not in your insurance network, then you will pay per the plan rules.
Transgender Benefits In California Only
The incorporation of transgender health reassignment benefits applies to all individual, family, small group and large group plans. It does not apply to self-funded plans where Anthem Blue Cross is the Administrative Services Organization. Transgender benefits will be included in all new Covered California health plans that become effective January 1, 2014.
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Telemedicine Takes Transgender Care Beyond The City
Shortages in rural health care workforces, low rates of insurance coverage, and long distances from health care facilities have made it challenging for many Americans outside urban areas to find high-quality, affordable health care. Transgender people in rural areas often face particularly acute challenges when it comes to finding competent providers and obtaining health insurance.
Douglas Knutson, a psychologist who studies health and resiliency among LGBTQ populations at Southern Illinois University, said rural trans populations often have high rates of anxiety, depression and suicidality.
That doesn’t mean they’re all eager to flee. Connections to home, land, language and heritage are powerful, said Knutson: “People have specific reasons for living in rural areas.”
Lange certainly does. Although she would love to be in a more welcoming environment, she remains in Houston County because of her son. “I’m a good parent,” she said. “I love him too much and I’m not going anywhere.”
She also has no intention of leaving law enforcement. If she did, she’d be leaving behind a retirement plan. Plus, she was recently promoted to sergeant in criminal investigations, and she finds it deeply satisfying to help people and solve crimes.
Lange enjoys her job working in criminal investigations and was recently promoted to sergeant.
Lange hangs out at home with friends Balducci and Buchanon-Romano, who came over for a cookout.
“Increasingly,” she said, “I think they’d be surprised.”
What Kinds Of Therapy Does Blue Cross Blue Shield Not Cover
Like most insurances, it is not typical for Blue Cross Blue Shield to cover services unrelated to a diagnosable mental health condition, such as:
- Couples counseling – Couples counseling is typically not covered by insurance, because relationship issues, while a significant source of stress, are not considered a diagnosable mental health condition.
- Life coaching – Life coaching is not covered by insurance because it focuses on achieving personal goals, rather than treating a diagnosable mental health condition.
- Career coaching – Career coaching is not covered by insurance because it focuses on achieving professional goals, rather than treating a diagnosable mental health condition.
Blue Cross Blue Shield is also unlikely to cover therapy sessions occurring outside the therapy office, because of the greater potential for risk involved. While clients may sometimes benefit from services rendered outside of the therapy office, such as a client with an eating disorder needing support in the grocery store, or a client with a phobia of driving needing support in the car, these services are not likely to be covered by insurance and must be paid for out-of-pocket.
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Q What Is A Transgender Person
A. A transgender person is an individual that meets any of the following criteria:
a person who has, or has been diagnosed with, gender identity disorder or gender dysphoria
a person who has received health care services, including counseling, related to gender transition
a person who adopts the dress, appearance, or behavior of the opposite sex or
a person who otherwise identifies himself or herself as a gender different from the gender assigned to that person at birth.
Anthem Blue Cross Transgender Language
Anthem Blue Cross doesnt make the EOCs easily available, but as an agent I can download Blue Cross EOCs attached to an existing client. Consequently, I dont have all the EOCs for all the individual and family plans offered in California. While reviewing one of the 2015 Blue Cross EOCs about another issue I tripped across the transgender language for their Gold PPO Multi-State plan.
Precertification is required for certain Transgender Services .
Benefits are provided for services and supplies in connection with Gender Transition when a Physician has diagnosed You with Gender Identity Disorder or Gender Dysphoria. Benefits are provided according to the terms and conditions of this Agreement that apply to all other medical conditions, including Medical Necessity requirements, Precertification and exclusions for Cosmetic Services.
Some services are subject to prior authorization in order for coverage to be provided. Please refer to the part GETTING APPROVAL FOR BENEFITS for information on how to obtain the proper reviews.
Transgender Surgery Travel Expense. Certain travel expenses incurred by the Member, up to a maximum $10,000 Anthem payment pertransgender surgery or series of surgeries , will be covered. All travel expenses are limited to the maximum set forth in the Internal Revenue Code, not to exceed the maximum specified above, at the time services are rendered and must be approved by Anthem in advance.
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How Much Does Therapy Cost With A Blue Cross Blue Shield Plan
If you choose a therapist who is in-network with Blue Cross Blue Shield, your therapy sessions likely cost between $15 – $50 per session, after you meet your deductible. The $15 – $50 amount is your copay, or the fixed amount that you owe at each therapy visit. The deductible is the total amount you need to spend in medical costs in any given year before your health insurance begins to cover the cost of services. Here are examples you may see on your Summary of Benefits under the In-network Outpatient Mental Health category and what they mean:
- $15 copay, after $5,000 deductible After you spend $5,000 in medical costs this year, your therapy sessions will cost $15 per session.
- $15 copay, after $1,000 deductible After you spend $1,000 in medical costs this year, your therapy sessions will cost $15 per session.
- $15 copay, deductible does not apply Your therapy sessions will cost $15 per session regardless of your deductible amount .
- 20% coinsurance, after $5,000 deductible, therapist charges $100/session After you spend $5,000 in medical costs this year, your plan will reimburse you $80 of your therapy session fee your effective therapy cost is $20/session.
- 20% coinsurance, after $1,000 deductible, therapist charges $150/session After you spend $1,000 in medical costs this year, your plan will reimburse you $120 of your therapy fee each time you submit a claim your effective therapy cost is $24/session.
Does Blue Cross Blue Shield Cover Bioidentical Hormone Therapy Does Insurance Cover Bioidentical Hormones
Blue Cross Blue Shield does not cover bioidentical hormone therapy or bioidentical hormone pellets, and its far from being the only health insurer that wont cover bioidentical hormone therapy. In fact, no insurance covers bioidentical hormones, bioidentical hormone pellets, but will cover the lab work necessary to calculate the optimum dose of the bioidentical hormones.
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Blue Cross Blue Shield For Therapy
Find vetted therapists who are in-network with Blue Cross Blue Shield
Blue Cross Blue Shield is one of the largest health insurance companies in the U.S., providing coverage for one in three Americans — including mental health, behavioral health, and therapy services. This guide outlines Blue Cross Blue Shields coverage of therapy services.
Does Blue Cross Blue Shield Cover Therapy
Yes, the vast majority of Blue Cross Blue Shield plans cover therapy.
Health insurances offered through the or through small employers are required by the Affordable Care Act to cover mental health services, and while not required by federal law, the vast majority of large employers also cover mental health services.
Find therapists in-network with Blue Cross Blue Shield
While rare, your Blue Cross Blue Shield plan may not cover therapy services if:
- You work for a large employer that does not include mental health benefits in its insurance coverage.
- Your health insurance plan was created before 2014, when the ACAs requirement that health insurance plans cover mental health services was enacted.There are other situations in which your Blue Cross Blue Shield plan may not cover the specific type of therapy service you are seeking, or where your coverage may not apply until you spend a certain amount on medical services first. Learn more about these cases below.
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Good Overall Review Of Benefits
Blue Shield of California had released amendments to their plans earlier in the year addressing the coverage for transgender benefits. The Anthem Blue Cross Frequently Ask Questions about the new coverage is far more in depth, explaining how they will handle the coverage. From the FAQ which can be downloaded at the end of this post.
Bioidentical Hormone Pellets Are Natural And Designed For Humans
Traditional hormone replacement therapies use synthetic, lab-made hormones. Its common for traditional pharmaceuticalhormone replacement therapies to create synthetic estrogen using the urine of a pregnant horse.
Instead, bioidentical hormones are derived from plant estrogen, a more natural source, and are adjusted so they are molecularly identical to the hormones our bodies used to naturally produce. Bioidentical hormone pellets are custom compounded in pharmacies to suit your bodys needs and restore your bodys natural hormone balance.
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What Should Be Included In The Cost Of Your Testosterone Therapy
Another import consideration when evaluating the costs of your low testosterone treatment, is that you must take into account exactly what is included in a price that you may have been quoted for testosterone replacement.
Does the price for testosterone treatment include other aspects of your testosterone therapy beyond just the cost of your testosterone prescription, such as blood tests, follow-up doctors visits, and perhaps some additional nutritional supplements? Make sure when you get a quote for the monthly fee for low testosterone treatments, you know what else is included, and exactly what you are getting.
Bioidentical Hormone Therapy Changes Lives For The Better
For women who are starting menopause or are in menopause, its common to suffer from the following symptoms:
- reduced libido or pain during sex
- vaginal dryness
- loss of energy and fatigue
- hot flashes
- night sweats and problems sleeping
- weight gain and foggy thinking
Bioidentical hormone therapy effectively eliminates those menopausal symptoms, resulting in a happier, healthier you.
Even men are helped when they use bioidentical hormone pellets. Men go through andropause as they age, just like women go through menopause when they age. Men also suffer from:
- loss of energy and fatigue
- problems sleeping
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Covered Equivalents For Drugs Not On Our Formulary
Our three plan options have certain drugs that are not covered on their formularies. Each non-covered drug has safe and effective, alternative covered drug options. You can see the list of whats not covered and available alternative options for Standard Option and Basic Option. FEP Blue Focus members can apply for coverage of a drug not covered on their formulary with the Non-Formulary Exception Process form.
Some Health Plans May Lag
Gender Health Center in the parade
Because this is a California state law that pertains to plans managed by the California Department of Managed Health Care and the California Department of Insurance, all health insurance plans will need to cover the transgender benefits. Anthem noted that all requests for services must be manually entered as they update their system to handle the procedures and codes. Expect similar issues with the other insurance carriers.
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What Mental Health Conditions Does Blue Cross Blue Shield Cover
Mental health conditions Blue Cross Blue Shield covers may include:
Note that therapists are required to assign you a diagnosis for the above conditions, as well as share the diagnosis with your health insurer, if you are using insurance benefits to pay for therapy.
If you dont want your insurance company to have access to this information about your mental health, consider out-of-network options instead.
Does Health Insurance Cover Testosterone Therapy Generally Yes But What If It Doesnt
Usually, your health insurance does cover testosterone therapy if your medical care provider can show a need.
However, not everyone has health insurance.
And sometimes, even when you have health insurance, you may be stuck paying out of pocket for one reason or another. For instance, your hormone levels may not be technically low enough to demonstrate a need to your health insurance company, but you may still be experiencing symptoms.
Fortunately, the cost of testosterone replacement therapy is very reasonable, even when paying out of pocket.
Generally, $299 a month is enough to cover the cost of weekly testosterone injections, injections that you can get quickly and easily, without a long wait. We also offer flexible hours and multiple locations, giving you the ability to get therapy when and where it best suits you.
Most of our patients who pay out of pocket find that the benefits of feeling happy, healthy, and like themselves again far outweigh the coststhey see the value in therapy.
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