Prior authorizations: UGH, right? Chances are, if you’ve tried to access healthcare, and especially gender affirming healthcare, using insurance, you’ve run across a Prior Authorization (PA, also Prior Approval.) What’s the scoop behind them? (February 2024)
What Is A Prior Authorization?
In many insurance plans, there are three categories of care:
- covered services
- uncovered services
- services covered with prior authorization
Covered services are those that insurance pays for without (too much) bother. Under ACA plans, some of these include yearly well-visits, contraception, and screening tests.
Uncovered services are those that insurance will never pay for. In many plans, these include elective procedures (those that you decide that you want but are not necessary to treat or prevent a disease, illness, or negative impact on well-being*) and some procedures, if done more often than the plan covers. An example of this is getting your vision prescription calculated (refracted.) Many plans will cover refraction once a year or once every two years, but not twice a year.
*Historically, many gender affirming procedures have been called “cosmetic” or “elective” by insurance companies and therefore not covered by insurance. Although there is still a long way to go, this is changing as more insurance plans are recognizing the gender affirming care is medically necessary.
What is Medically Necessary?
Health.gov’s definition is:
Medically necessary
Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
What’s a Standard of Medicine?
A standard of medicine is a general agreement that a particular procedure, medicine, or intervention is the one that is most likely to benefit the patient when balanced by time, risk of negative side effects, and expense, hopefully informed by high-quality research. There are lots of different groups that determine standards, and there isn’t always agreement about exactly what medical providers should do when and how to treat an illness. Standards evolve, and most governing bodies review their standards regularly to incorporate new evidence. Not everyone agrees, but when you reach the tipping point where more trustworthy organizations say “do X” rather than “do Y,” a standard is developed and maintained.
When we contact legislators about youth care bans, we argue that gender affirming care is medically necessary and an accepted standard of medicine according to the many different organizations that have published guidance about caring for transgender, nonbinary, and gender-expansive youth, and who have expertise in the treatment of these populations. Furthermore, there are many more organizations that support gender affirming care for youth, and those organizations have more members, more prestige, and more scientific trust and expertise than those who do not support gender affirming care as a medical standard. See the link above for an example letter we’ve sent to state legislatures.
Want To Know More?
The United States Preventive Services Task Force (USPSTF) is the major organization in the U.S.A. that reviews and publishes guidelines about the medical standards for preventive care. They’re the ones who review the research studies and develop recommendations for how often you should get your cholesterol, blood pressure, and blood sugars checked, screened for various types of cancer, and a slew of other conditions that we can prevent.
Back To Prior Authorizations
Prior Authorizations come into play when insurance companies will pay for a medicine, procedure, course of treatment, or other intervention after you’ve asked them very nicely and explained why the intervention is needed. Often, insurance companies want a statement describing why this action is medically necessary for this person under these circumstances.
Many times, prior authorizations are required so that insurance knows that:
- the patient and provider are following generally accepted best practices
- the less expensive options were tried first
- the more effective options (as understood by the evidence) were tried first
Sometimes, if you switch insurances after going through the process to find the right medicine for you under a different insurance, you’ll need to complete a prior authorization proving that you’ve already tried the recommended medicines and they don’t work well enough for you, so pretty please, please, may you have the one that you knows works for you as a covered med? Anyone with brain meds or non-injectable hormones may know this annoyance well.
In Gender Affirming Care, Prior Authorizations Are Common and Often Ask:
- has the person been diagnosed with gender dysphoria according to the DSM V?
- either by a mental health provider or a medical provider
- how long has the person been dealing with this?
- has the person talked to a mental health provider about this, and for how long?
- does the mental health provider agree with the person that the next step is appropriate?
- has the person talked to a medical provider about this?
- have they tried hormones, and for how long (except if starting hormones)
- does the medical provider agree with the person that the next step is appropriate?
- has the person received sufficient information about what to expect (informed consent, baby!)
- does the person have any co-occurring conditions that may make the next step riskier or more dangerous?
We don’t necessarily agree that all of this information should be required before a procedure is paid for. Some states and insurance companies are reducing the conditions necessary for prior approval.
As we all know, some states and insurance companies are making it harder!
Here’s Examples from the Washington Medicaid (Apple Health) Program:
To receive gender affirming surgeries that Apple Health pays for, you must:
- get care from a provider that Apple Health recognizes
- have been on hormones for 12 months unless there is a medical reason for not taking it
- hormones aren’t required for top surgery
- you’ve been “living as” your gender identity for 12 months unless it isn’t safe for you to do so
- this is not required for flattening top surgery, orchiectomy, or hysterectomy
In addition, you must:
- be evaluated by a mental health provider with a certain level of education and they have provided a letter of support. Both within the 18 months prior to surgery.
- This letter attests that
- yep, you’re diagnosed with gender dysphoria
- you’ve “lived as” for 12 months, or
- there are safety reasons preventing you from doing so, or
- you want top flattening surgery, orchiectomy, or hysterectomy
- you have been evaluated for coexisting behavioral health concerns and those are managed if you have any
- This letter attests that
- have a supportive letter from the person who prescribes your hormones within the last 18 months, or
- if you’re not taking hormones, a letter from your primary care provider
- chart notes from your surgeon or provider detailing their evaluation and treatment plan within the last 12 months.
Who Submits the Prior Authorization?
It depends on what you’re trying to get covered and who your provider is.
For prescriptions, either your prescribing provider submits the PA or your pharmacy does when they reach out to your insurance.
For procedures such as hair removal, either your hormone provider, your primary care provider, or your surgeon will submit the PA.
For surgeries, often your surgeon or their office manages PA requests. Sometimes your hormone provider or primary care provider will start the process.
How Long Does It Take?
It depends.
A PA might take 20 minutes of office time for your prescriber or their staff. It could take hours of back-and-forth messages, phone calls, documentation, and meetings.
How Much Does It Cost?
Usually, there is no separate charge to you. We don’t accept insurance for appointments, but we will help you use insurance for your prescriptions.
If we are writing a surgery referral letter for you, and we are having trouble getting your prior authorization approved, we may ask that you book additional referral consult appointments to help pay for red tape time.
Our sliding scale includes a calculation of how much time we spend both in and out of appointments to help manage your care. An hour-long introductory appointment may require 2 or more hours of staff time.
How Do I Find Out What I Need For My Prior Authorization?
The most complete answer is to contact your insurance provider and ask them. You can also search online for their gender affirming care policy. This policy will provide details on what information is required for prior authorization approval. You might find this policy by searching “gender dysphoria treatment policy” plus the name of your insurance.
Here’s an example from Regence.
What Needs Prior Authorization?
Your Summary of Benefits document might indicate some procedures that need prior authorization such as diagnostic imaging or hospital stays. Your plan’s Drug Formulary may contain information about which prescriptions need a PA. Find out more about health insurance plan documents here.
Can someone else do it?
Sure! We offer Care Navigation as do many other organizations, including TransFamily Support Services Check with your local LGBTQ+ Community Center for free, reduced cost, and nearby resources!
Related Articles
- Insurance Dictionary
- How to Find A Gender Affirming Provider Who Takes Your Insurance
- 10/23 Is Insurance Required to Cover Gender Affirming Care in WA State?
- Helpful Resources for Navigating Insurance
- Tips For Talking To Insurance: Procedures, Policies, Payments, and Appeals:
- What Does My Plan Cover? Health Insurance for Gender Affirming Care
- Funding Trans Healthcare in 2024 | Money for Gender Affirming Care
