I’m a transgender person living in California.
What do I need to know about Health Care Reform?
HEALTH CARE REFORM BASICS
President Obama’s health care law, the Affordable Care Act, or ACA – also known as Obamacare – is changing the way people can access Medical care with health insurance in the United States. One key provision of the Affordable Care Act is the “individual mandate,” which says that most people living in the U.S. must have health coverage beginning in January 2014. This means that if you are currently uninsured, you are required to get health coverage, either public or private, or pay a penalty. In 2014, the penalty is 1% of your annual income, or $95, whichever is higher. Government subsidies and cost assistance may be available for people who cannot afford a policy on their own.
- If you are a U.S. citizen or permanent resident, you have new options for health insurance, which are designed to make health care more affordable. If you are low income, you may be eligible to enroll in Medi-Cal. If you don’t meet the eligibility requirements for Medi-Cal, you can take advantage of the new health insurance shopping marketplace set up by the State of California, which is called Covered California. Read on to find out which options are best for you.
- If you have a low income, you may now be eligible to enroll in Medi-Cal, California’s Medicaid program. Previously, eligibility requirements for Medicaid have focused on minors, mothers of young children, and adults with specific types of disabilities. However, under the Affordable Care Act, California is expanding Medi-Cal to include single adults without disabilities, and increasing the income limit for individuals and families. If your 2013 household income (as you report on your federal taxes) is at or below 138% of the federal poverty level, you are eligible to enroll in Medi-Cal. For single adults, 138% of the federal poverty level is $15,900; for a family of 4, 138% of the federal poverty level is $32,499. A table of federal poverty level proportions and household sizes is available on page 8 of Covered California’s health plan booklet here.
- If you are not eligible for Medi-Cal, you can still take advantage of new health care options made available by the Affordable Care Act. Each state has established a new, centralized marketplace where you can compare and shop for health insurance plans. In California, this marketplace is called Covered California.
- All insurance plans available through Covered California have been vetted to ensure that they meet standards set forth by the Affordable Care Act. These qualified health plans have limits on out-of-pocket expenses and must offer 10 essential health benefits, which include preventative and wellness care, mental and behavioral health care, prescription drug coverage, lab services, and more (for the full list and an explanation, click here.)
- Insurance plans available through Covered California are sorted into 4 categories (“metal tiers”), based on how expensive they are to the consumer. Bronze plans offer the lowest premiums (monthly costs), but the highest out-of-pocket costs (such as copays) – these plans are best suited for someone who doesn’t need many visits to the doctor. At the other end are platinum plans, which have the highest premiums and lowest out-of-pocket costs. In the middle are gold and silver plans. For descriptions of metal tier plans, click here.
- Buying insurance as an individual can be very expensive, but the Affordable Care Act has provisions to subsidize the up-front costs to consumers. If your income for 2013 is between 139% and 400% of the federal poverty level ($15,901 – $45,960 for single adults, $32,500 – $94,200 for a family of four), you are eligible for financial assistance with the premium (monthly) cost of any insurance plan offered through Covered California. If your 2013 income is between 139% and 200% of the federal poverty level ($15,901 – $22,980 for single adults, $32,500 – $47,100 for a family of four), you are eligible for additional subsidies for out-of-pocket expenses such as copays for office visit and prescriptions. To find out what your monthly costs can be for a silver plan, try Covered California’s online cost calculator.
MEDI-CAL AND TRANSITION-RELATED HEALTH CARE
- Medi-Cal covers some transition-related care, as well as the full range of gender-specific care (e.g., mammograms, pap smears). Cross-gender hormone replacement therapy is a covered benefit, as are some forms of gender reassignment surgery. Surgical treatment options are approved on a case-by-case basis. For more information about Medi-Cal and transition-related care click here.
COVERED CALIFORNIA AND TRANSITION-RELATED HEALTH CARE
- Regardless of metal tier, each qualified health plan must comply with California’s 2006 Insurance Gender Nondiscrimination Act and regulations from the California Department of Managed Health Care and Department of Insurance. In combination, state law and regulations have said that health insurance companies cannot make coverage exclusions that single out medically necessary care for transgender people (this excludes self-insured plans, most common at large organizations, which are regulated at the federal, not state, level.) However, this does not mean that all gender reassignment surgical treatment options are pro-actively covered, as some insurance carriers are still pushing back about whether they have to cover certain types of treatment. For more information about the effects of California law and state regulations, see our FAQ.
- Beginning October 1, you can enroll online by visiting http://www.coveredca.com, via phone at (800) 300-1506, or in-person with a certified Covered California enrollment counselor.
- Whether or not you have insurance, you can always look for a trans-friendly doctor by searching in the Gay & Lesbian Medical Association’s Provider Directory, available online at http://www.glma.org.