This brochure was created to help people understand the procedural steps one should consider to appeal a health care denial for health care plans that are managed by the California Department of Managed Health Care (DMHC), the California Department of Insurance (CDI) or Medi-Cal. This handout does not provide the substantive points you should include as part of your appeal. For assistance regarding what documents should be included or for tips negotiating for health care with your employer, see our publication Transgender Health Benefits: Negotiating for Inclusive Health Insurance Coverage.
About Health Insurance
Many transgender people will access health insurance for the first time as a result of expanded Medicaid and subsidized private health plans through the Affordable Care Act. For those of us who are used to paying cash for health services (or not being able to access them at all), adding insurance to the mix can be confusing, overwhelming, and frustrating. The biggest difference between a cash model and a health insurance model is that insurance plans put limits on which health care providers you can go to, for both regular health care (primary care) as well as specialists such as surgeons. Further, insurance companies usually put a policy in place that outlines requirements for eligibility and documentation for accessing transition-related care. It is essential to follow these requirements to the letter in order for the insurance company to approve your treatment.
We encourage everyone seeking transition-related care to ask your primary care provider to submit a preauthorization request to your insurance company for the procedures you are seeking. This allows you the peace of mind of engaging in any appeals that may be necessary before any expense has been incurred. Once your provider’s office has submitted paperwork to the insurance company, either for a preauthorization or for as a bill after the procedure, the insurer will send an Explanation of Benefits (EOB) to you and your provider, either along with payment to the provider, or with a notice saying payment has been denied. If payment has been denied, we refer to this as an “insurance denial”.