Insurance

last updated

Created By Rainbow Health Initiative

Starting with the 2019 coverage year (for which you will file taxes in 2020), there is no longer a tax penalty or “individual mandate” for having health insurance. There are multiple ways to access inclusive insurance plans, as well as programs to help lower costs. Based on your income you may not have to pay anything for your insurance plan and if you do pay for a plan, you will most likely qualify for a tax break.

As of late 2009, all employers in Minnesota with 11 or more full-time employees are required to offer health insurance to their employees using pre-tax income. This means that, if employed, you may already be eligible for a care plan through your workplace using your pay before any tax deductions are taken from it, which in turn helps save money. As of 2015, married spouses (regardless of gender) can also seek coverage through their spouse if the insurance company offers spousal coverage. Unmarried partners can no longer seek coverage through their partner’s insurance now that marriage rights have been amended.

If you are not currently employed full-time, or covered through a spouse, there are insurance plans available to you through MNsure, the state’s insurance program.

Here’s a flow chart of all the different ways you might access insurance in Minnesota. In this chart, FPL stands for Federal Poverty Line.

Essential Health Benefits

The Patient Protection Affordable Care Act (PPACA) outlined ten (10) specific Essential Health Benefits (EHB) that every health care plan must offer. Every plan must meet a minimum standard of quality, and must also allow you to have balanced access to your benefits. This means a plan cannot focus on one EHB and ignore the rest. Additionally, to meet nondiscrimination standards any essential health benefit services that are covered for cisgender people must also be covered for transgender people.

Essential Health Benefits:

1. Ambulatory patient services (outpatient care you get without being admitted to a hospital)
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
6. Prescription drugs
7. Rehabilitative and habilitative services and devices (to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
8. Laboratory services
9. Preventive and wellness services and chronic disease management. Check here for a full list of preventative services guaranteed by the Affordable Care Act.
10. Pediatric services, including oral and vision care

Insurance Terminology

Ambulatory Care

Ambulatory care refers to outpatient treatments such as doctor office visits, and includes more routine care that is conducted outside of a hospital inpatient setting.

Benefit

A benefit in an insurance plan is a service type or test that you have coverage for. This can cover anything from yearly physical exams to blood work.

Co-Pay

A co-pay is a part of the medical cost that you are responsible for when receiving care. Co-pays are usually listed on the back of an insurance card, and are a set amount. (e.g. a co-pay of $10 for a doctor office visit.)

Co-Insurance

A co-insurance is a percentage of a medical cost that you are responsible for on a service to service basis. For example, if you are having a minor surgery, you may be responsible for a co-insurance of 15%, meaning 15% of the total cost of the surgery will be your responsibility to cover. Co-insurance rates can change for different procedures, so call your insurance company to best know your different co-insurance rates.

Deductible

A form of cost sharing where there is a set amount of money that you are responsible for before insurance coverage begins. Normally, deductibles are not applied to general doctor’s office visits, and come into effect when more complex procedures are required. Deductibles can range from <$500 to over $3,000.

In-Patient/In-Patient Care

Treatment that is provided in a hospital setting and where the patient is receiving on-going care inside the hospital.

Outpatient/Outpatient Care

Treatment that is provided outside of a situation in which the patient is hospitalized. This include minor surgeries that can be completed safely in a doctor’s office.

Premium

A premium is the overall cost of the health insurance plan that you are responsible for paying. Normally, this is divided up into monthly payments to make the cost more accessible.

Joining an MNsure Insurance Plan

See if you qualify for medical assistance

See if you can join a MNsure plan outside of the open enrollment period

If you don’t have access to insurance through an employer or school, there are yearly open enrollment periods to purchase insurance plans. Yearly open enrollment periods are in the late fall, but the exact weeks vary. However, you may also apply for insurance coverage outside of the open enrollment period if you have had a qualifying life event, like changing jobs, adding a child to your family, or getting married.

Enrollment can be completed individually online, or can be done with the assistance of a MNsure Navigator. Navigators are people trained to help you through the enrollment process, and provide help determining what plans would work best for your needs. If you are looking for a MNsure Navigator that is LGBTQ competent in the Twin Cities, you can make an appointment with a Navigator at JustUs Health, Family Tree Clinic, or OpenCities Health Center. Check the resource list for contact info.

When you go on MNsure.org, you’ll be asked to enter information about yourself and your household to determine what plans you qualify for. Depending on your income, if you qualify for MNcare or MA (medical assistance) the site will indicate that you qualify and that you’ll get further information in the mail about completing your application.

If your income is high enough, you’ll be able to select from a list of insurance plans with varying costs (co-pays, premiums, deductibles, and co-insurance). Each plan will have a short Summary of Benefits and Coverage that you can look at to compare plans. Each Summary of Benefits and Coverage has two coverage examples to see what the plan would cover in common medical situations. You may still wish to call the insurance company and get specific coverage information and criteria if your condition or needs aren’t listed in the Summary of Benefits and Coverage. Private plans within MNsure are expected to cover counseling, hormones, and medically-necessary surgeries for adults; for minors, counseling and medications should be covered. However, trans people seeking medical transition and parents of trans children with medical transition needs may want to call the insurance company directly about the plan to get coverage criteria about transition related care before selecting a plan. This is where working with a MNsure navigator may be helpful, since it’s another person to help advocate for you.

After completing the online application, a bill for your premium will be sent to your house. After paying the first installment, your coverage will begin and your insurance cards will be sent to you. Until you pay this first installment, you do not have coverage, unless you are entering with special enrollment. This is important to remember. Know that until your coverage officially begins you will be responsible for any medical costs or visits you make.

For new citizens and refugees, medical insurance is provided as you transition to living in Minnesota.

See what coverage you are eligible for.

Note: For undocumented people, these services are not yet available.

Transition Related Care and Insurance

Medicaid

If you are on Medicaid in Minnesota, the only transition related services covered are hormone therapy and mental health services, if defined as medically necessary by your provider. Currently Minnesota has defined transition related surgeries as exploratory surgery by Medicare, which is not covered. For surgery to be covered by insurance, trans care related exclusions will need to be removed.

Medical Assistance (MA)/Minnesota Care

If you are currently on MA/Minnesota Care counseling and transition-related medication is covered for adults and minors. Medically-necessary surgeries are currently covered for adults. In November 2016, a Ramsey County judge declared a prior MA surgery ban unconstitutional. More information on what procedures are covered is available here. DHS has also published information on the coverage for minors of testosterone and blockers in these programs.

The Minnesota Department of Human Services’ website lists a number of services it considers cosmetic and thus not covered. However, in at least one case, a DHS administrative ruling concluded that this list was not enforceable. Similarly, DHS has indicated that one must be at least 18 to have any form of gender confirmation surgery, but in at least one case, DHS agreed that this did not apply to top surgeries for trans males under 18. If you are a minor or seeking a transition-related service that is currently on the list of procedures DHS considers “cosmetic,” it may be still worth pursuing coverage through you MA/Minnesota Care plan. Please feel free to contact us at www.justushealth.org/legal for more information or assistance with this or similar questions.

Medicare

Medicare in Minnesota covers the full range of transition services. Coverage is determined on a case-by-case basis, which is no different than how Medicare handles coverage for most other medical procedures. Click here to learn more.

Employer or School Based Insurance

If you are receiving health insurance through your employer or school, in addition to knowing about your co-pays and deductibles, you may want to find out if the plan is fully-funded or self-funded. Fully-funded plans are when a company has each employee pay into a shared account for health care. The company then takes these funds and purchases plans through an insurance provider. Fully-funded insurance plans are subject to both federal and state laws. Minnesota Department of Human Rights has concluded that health plans subject to state law may not arbitrarily exclude transition-related care.

Self- funded plans are when a company has each employee pay into a shared account for health care. The company then hires an insurance provider to deal with any paperwork and billing accrued by employees seeking care and bills the company’s shared account for any healthcare costs. This means that the company simply creates a large fund to cover any medical expenses. Self-funded plans are subject only to federal laws, not state laws.

Please note that when Marriage Equality was deemed the law of the land in 2015, employers began terminating access to partner benefits and began to require couples to be legally married to receive these benefits.

Just like plans available through MNsure, plans through an employer or your school will have a Summary of Benefits and Coverage in addition to the full policy available for you to read through. It’s a good idea to read the plan and be sure you understand what your co-pay, deductible, premiums, and co-insurance may be.

In 2012, the Minnesota Department of Human Rights concluded the MHRA bars transgender-specific exclusions in health plans subject to state law. Additionally, in 2015, the Minnesota Department of Health and Commerce advised insurers that they would not approve policies with such exclusions for sale in the private market in Minnesota.

Beginning in 2016, the Federal Equal Employment Opportunity Commission (EEOC) began interpreting federal employment law, applying to employers with at least 15 employees, to bar such exclusions in employers’ self-funded pans.

Read more about health insurance, transition related care, and advocacy on Lambda Legal’s website.

Getting Care Covered

What is a medical necessity? Is that different from a covered service?

Unfortunately, in the world of insurance a medical necessity is not the same as a medical benefit. In the world of insurance, a medical necessity is something that your doctor has decided is necessary. A medical benefit is something that your insurance plan has agreed to cover. Sometimes, your doctor might decide you need medical care that is not covered by your insurance policy. Insurance companies determine what tests, drugs and services they will cover. Your insurance company’s choices may mean that the test, drug or service you need isn’t covered by your policy.

What should I do?

Try to familiarize yourself with your plan. It’s good to know what your insurance company will pay for before you receive a service, get tested or fill a prescription. Some kinds of care may need to be “pre-authorized” by your insurance company before your doctor can give you the service. For example, a lot of transition related medical care for transgender people currently requires pre-authorization.

If you have questions about your coverage, call your insurance company and ask a representative to explain it. This can feel challenging and scary. Take deep breaths, and feel free to write down what you want to ask before you call. Be sure to take notes so that if you experience discrimination you can report it later. You deserve great care and respect.

Your insurance company, not your doctor, decides what your health plan will and what it will not pay for.

What if my doctor recommends care that isn’t covered by my insurance?

Ideally, all of the care your doctor recommends will be covered by your plan, but sometimes this doesn’t happen. If you have a test, treatment, or medication that isn’t covered, your insurance company won’t pay for it, which is sometimes called a denied claim.

If your insurance denies your claim, you can challenge or appeal the decision. The appeal process should be outlined in your plan documents, and you can also ask your doctor for support in making appeal.

Additionally, if your claim is denied and you feel it was because you are lesbian, gay, bisexual, transgender, or queer, you should consider filing a complaint with the Department of Health and Human Services and the Joint Commission.

Insurance And Trans People

Since 2012, it’s been illegal to deny transgender people care simply because they are transgender. However, until the recent proposed HHS ruling it was unclear whether or not that extended to requiring insurance plans to cover transition-related medical care and procedures. As of September 2015, 10 states and the District of Columbia have already decided that it will not allow insurance plans sold in their state to include categorical exclusions of transition related care.

The new proposed ruling to implement the nondiscrimination clause of the Affordable Care Act clarifies that “the law prohibits discrimination in many health facilities and insurance plans based on race, national origin, age, disability, and sex — including bias based on gender identity. These rules would make it illegal to categorically deny health care coverage related to gender transition, exclusions that still appear in the vast majority of private and public health insurance plans in the United States. Instead, plans must cover medically necessary medications, surgeries, and other treatments for gender dysphoria for transgender people if they cover similar services to non-transgender people with other medical conditions.”

HHS is already enforcing this ruling, when it is finalized and goes into effect officially it will make it easier to enforce. Any complaints received by Health and Human Services must and will be reviewed, whether it’s before or after the final ruling is implemented.

If your insurance plan is denying you coverage for transition related care, you can appeal that decision. Reach out to JustUs Health, Gender Justice or OutFront for more assistance in appealing insurance claims, filing discrimination claims and lawsuits for a lack of coverage in your insurance plan. You should also file a report with the Joint Commission and file a complaint with the Department of Health and Human Services.

MNSure LGBTQ Navigator Organizations

JustUs Health
2577 Territorial Rd
St. Paul, MN 55114
612-341-2060

OpenCities Health Center
409 North Dunlap St.
St. Paul, MN 55104
651-290-9200

Family Tree Clinic
1619 Dayton Ave #205
St. Paul, MN 55104
651-645-0478

Resources

Family Tree Clinic
1619 Dayton Ave #205
St. Paul, MN 55104
651-645-0478

Gender Justice
550 Rice Street
St. Paul, MN 55103
651-789-2090

OutFront Minnesota
310 East 38th Street, Suite 209
Minneapolis, MN 55409-1337
612-822-0127
Toll-free: 800-800-0350