California

California has on-paper rules mandating full transition coverage (including surgery) for both Medicaid and private health insurance. In practice, for both Medicaid and private insurance you will have to go through an appeals process if you seek surgery.

For personal help on California insurance, contact the Transgender Law Center for free assistance at 415.865.0176, extension 306 (www.transgenderlawcenter.org).

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What is covered?
Medi-cal is required to cover "hormone treatment, gender reassignment surgery, and other necessary procedures". They will typically attempt to deny funding for surgical procedures, but there is a process to override the denial by going to a court.

What is the process?
For hormone treatment, the process is straightforward. Just find a endocrinologist or clinic (contact your Medi-cal provider to find one) and the treatment will be billed in the normal fashion.

For surgery, additional steps will be required. The Transgender Law Center has a guide on this process:


 * 1) First, you have to find a surgeon is willing to take Medicaid funding (see below).
 * 2) Your surgeon should submit a document called a Treatment Authorization Request (TAR) to Medi-Cal.
 * 3) * The TAR is the document that will be used throughout the process to establish the medical necessity of surgery. The TLC suggests that the TAR should include "letters from your therapist or therapists, a letter from your primary physician, and a letter from you" all explaining why the surgery is medically necessary.
 * 4) After 30 days, Medi-cal will contact you with a result. If your request is denied:
 * 5) The denial will come with a "Notice of Action". On the back of this notice is a form you can use to request a "Fair hearing". Within 90 days, you must fill out and submit this form.
 * 6) You will be contacted back with a date for a hearing.
 * 7) For the hearing, the TLC strongly recommends getting a lawyer. In some areas, you can find lawyers who will take your case for free. If you are in the Bay Area, contact Bay Area Legal Aid at 510-663-4755 (baylegal.org). Otherwise, contact the Transgender Law Center (see top of page) to see if they know of free legal help in your area.
 * 8) At the hearing, you will have to submit evidence that your surgery is medically necessary. See the TLC guide above for information on what to submit.

This process is known to have worked for genital surgery and mastectomy. It may work for other procedures such as hair removal or trache shave, but no one is known to have successfully gotten approval for this.

What is covered?
California odd

These regulations were put in place in mid-2013. Much about them is still unknown, and no one is known to have successfully completed an appeal.

What is the process?
The Transgender Law Center has a FAQ on this process :


 * 1) Apply with your insurer for whatever it is you want covered. Assume you will be denied.
 * 2) Once you are denied, file an appeal with your insurer. If you call them they will explain how to do this.
 * 3) Next, file appeal to a state board called the "Independent Medical Review" (IMR), which can override the insurer's denial:
 * 4) * If you have insurance through a PPO, call the Department of Insurance helpline at 1-800-927-HELP (www.insurance.ca.gov/contact-us/).
 * 5) * If you get insurance through an HMO, call the Department of Managed Health Care Help Center at 1-888-466-2219 (www.HealthHelp.ca.gov)
 * 6) * In either of the two above cases, say you want to file an "IMR appeal for reasons of medical necessity".
 * 7) * If you get stuck, contact the Transgender Law Center for free assistance (see top of page)

Both the Department of Insurance website and the Department of Managed Health Care website have more information about their respective IMR processes.

Legal basis
The requirement for insurance coverage is based on the following:


 * AB 1586 aka the Insurance Gender Non-Discrimination Act, a law passed in 2005.
 * For PPOs, California Code of Regulations (Click "Title 10", "Chapter 5", "Subchapter 3", "Article 15.1", "Section 2561.2: Discrimination on the Basis of Actual or Perceived Gender Identity"), as amended in 2013, a regulation founded in the IGNA.
 * For HMOs, California Department of Managed Health Care Letter 12-K, an April 2013 state advisory letter building on the IGNA.