Fees & Insurance
Trying to figure out insurance coverage for gender affirmation surgery can be stressful. Our team is here to provide you with guidelines and will work directly with your insurance company to see what gender affirmation surgery benefits you have. We will take you through every step of the way from helping you obtain the appropriate letters, providing specific guidelines for your therapist and adjusting those letters if needed until either you approval is achieved or when it becomes clear that you do not have coverage.
In-network vs. Out-of-network:
Dr. Chandler is in-network with Husky insurance (Connecticut Medicaid) which covers surgery at 100%. We are out-of-network with most commercial insurance companies, but because top surgery is such a specialized surgery, we can obtain partial coverage in most cases. Your first step is to contact us for a consultation. Once we have your information, we will contact your insurance company and determine your benefits, and you will be presented with one of the following scenarios:
Scenario 1. Your insurance does not cover the cost of your top surgery
Some insurance plans have specific exclusions for covering gender affirmation surgery or will deny your surgery based on their determination that you do not qualify based on their medical policy guidelines. We do not run into this very often, but occasionally this happens.
- Pay out-of-pocket for top surgery
In this scenario, you would be responsible for the entire cost of top surgery. The total estimated cost ranges based on the amount of work required for the surgery. The total cost includes surgery, anesthesia, facility, and all postoperative care.
- Finance your top surgery
We offer different types of financing, which usually involves some form of down payment and a monthly payment plan. Ask us for details if you are interested in this option.
- Request an exception through your insurance
Sometimes even if you have no out of network coverage through your insurance company, we can still request coverage through the insurance company through something called a Single Case Agreement. This is an agreement between your insurance company and us to agree to cover your surgery even though they don't normally cover out of network physicians. This is sometimes possible due to the nature of this type of surgery being a specialized surgery that is not possible to find everywhere. It is your insurance company's responsibility to make sure you have access to this type of surgery. We have had success for many patients using this method to obtain coverage.
- Obtain external coverage
There are several options that may be available to you if you are unable to get your surgery covered by insurance or if you are unable to finance your surgery. The following are some avenues for you to consider:
- Employees of Starbucks – Some of our patients who are current employees of Starbucks have found success in coverage for gender related procedures. If you happen to work here, you should explore this as an option. Starbucks supplemental insurance plans have been known to cover top surgery as well as adjunctive procedures such as liposuction.
- GoFundMe – Another option is to start a GoFundMe account and request assistance from friends and family in support of your surgery.
- The Talms Charity Foundation – An initiative to assist the Trans community worldwide with grants
- The Jim Collins Foundation – A foundation aiming to provide financial assistance to trans individuals for gender-affirming surgeries for those unable to finance the surgery themselves.
Scenario 2. You have commercial insurance which covers a portion of your top surgery (ex. Aetna, Cigna, United Health Care, Oxford, Blue Cross Blue Shield, Anthem)
We find this is a very common scenario for patients with commercial insurance plans who have out-of-network benefits and average deductibles associated with their plan. In this scenario, your estimated out-of-pocket cost for all our services is around $5000 but could be more depending on your insurance plan. The $5000 covers our concierge fee, and any additional fees would be based on your insurance benefits. This still requires that your insurance approves your surgery, so you still need to meet the criteria for top surgery, which is usually similar to WPATH guidelines but can vary by insurance plan. Insurance plans have their own medical criteria guidelines for top surgery, which sometimes you can find online on your insurance company’s website. If you have a high-deductible plan, your surgery cost may be as high as $10,000. You can check with your insurance company to find out if you have a high deductible plan.
Scenario 3. You have Connecticut State insurance (Husky)
If you are approved, your surgery will be covered 100% with no out-of-pocket surgery cost. You will need to meet criteria for approval which is very similar to the WPATH requirements for top surgery.
Connecticut Medicaid (Husky) Insurance Requirements for Top Surgery:
- Gender incongruence/diversity is marked and sustained
- If significant medical or mental health issues are present, documentation from the treating provider that they do not interfere with self-identification and do not put you at unreasonable risk
- You are stable on your hormone therapy unless contraindicated or not desired (note you do NOT have to be on hormone therapy to qualify for top surgery)
- You understand the effect of surgery on future reproduction/breast feeding
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