Insurance

At Radiance Surgery and Aesthetic Medicine, we believe that everyone deserves access to quality healthcare. Our team works diligently with various insurance providers and Medicare to ensure that you receive the coverage you need for your surgical procedures.

Navigating insurance can be overwhelming, but our dedicated staff is here to assist you. We will help you understand your benefits, provide detailed information about your coverage, and guide you through the pre-authorization process to minimize any financial stress.

Georgia Medicaid

• Coverage Status: Georgia Medicaid covers gender-affirming surgeries when medically necessary, following a 2022 settlement in Thomas et al. v. Georgia Department of Community Health. This settlement removed categorical exclusions for gender-affirming care, including surgeries, and applies to FGAS if medical necessity is established.
• Managed Care Organizations (MCOs): Georgia’s Medicaid program operates through MCOs like Amerigroup, CareSource, Peach State Health Plan, and WellCare, which have clinical guidelines for transgender-related care, including FGAS.
• Requirements:
  • Diagnosis of gender dysphoria by a qualified behavioral health provider.
  • Documentation of medical necessity, often including letters from mental health professionals or physicians.
  • Prior authorization, which may require evidence of hormone therapy (typically 12 months, unless contraindicated) and well-controlled medical/mental health conditions.
• Challenges: While FGAS is covered, only 17% of state Medicaid programs nationally explicitly include FGAS, and Georgia’s policy may not always be clear on specific facial procedures (e.g., rhinoplasty, thyroid chondroplasty). You may need to appeal denials with strong documentation.
• Action: Contact your MCO (e.g., CareSource via their portal or member services) to confirm FGAS coverage and required documentation. If denied, appeal with support from providers or advocacy groups like the ACLU of Georgia.

Commercial Insurance Providers

Many commercial insurers in Georgia cover FGAS if medically necessary, but 51% of policies nationally classify FGAS as cosmetic, which can lead to denials. Below are major insurers operating in Georgia and their general FGAS policies:

1. Anthem Blue Cross Blue Shield of Georgia
   • Coverage: Covers FGAS if criteria are met, including:
     • Age 18+ and capacity to make decisions.
     • Gender dysphoria diagnosis.
     • 12 months of continuous hormone therapy (unless medically contraindicated).
     • Facial features significantly different from the identified gender.
     • Letter of support from a mental health professional.
   • Covered Procedures: May include facial bone reconstruction, jaw contouring, rhinoplasty, thyroid chondroplasty, lip enhancement, and more, if medically necessary.
   • Note: Anthem updated policies post-ACA Section 1557 to reduce exclusions, but coverage depends on the specific plan.
2. Aetna
   • Coverage: Covers FGAS when medically necessary, following World Professional Association for Transgender Health (WPATH) guidelines.
   • Requirements:
     • Letter from a qualified mental health professional confirming gender dysphoria and readiness.
     • Documentation of hormone therapy (if applicable).
     • Prior authorization.
   • Note: Aetna’s policies align with federal anti-discrimination laws, increasing FGAS approval chances in Georgia.
3. United Healthcare
   • Coverage: Covers FGAS under commercial plans if medically necessary, per WPATH standards.
   • Requirements:
     • Gender dysphoria diagnosis.
     • Prior authorization.
     • Documentation, including mental health and medical provider letters.
   • Note: Coverage is case-by-case, and some facial procedures may face scrutiny as cosmetic.
4. Cigna
   • Coverage: FGAS is often classified as not medically necessary under standard plans, but specific procedures (e.g., thyroid chondroplasty) may be covered case-by-case.
   • Requirements:
     • Medical director review to assess necessity for gender presentation.
     • Extensive documentation, including mental health support letters.
   • Note: Cigna’s restrictive stance may require appeals to secure coverage.
5. CareSource
   • Coverage: As a Medicaid MCO in Georgia, CareSource covers FGAS under its gender dysphoria policy when medically necessary.
   • Requirements: Aligns with WPATH, requiring prior authorization, gender dysphoria diagnosis, and supporting documentation.
   • Note: Contact CareSource’s member services for Georgia-specific details.

Employer-Sponsored Plans

• Large Employers: Companies like Amazon, Google, Microsoft, AT&T, and Delta Air Lines (headquartered in Georgia) often offer self-insured plans covering FGAS. These plans typically follow WPATH guidelines and may cover procedures like rhinoplasty, jaw contouring, or thyroid chondroplasty if medically necessary.
• Example Case: In Houston County, Georgia, a sheriff’s deputy won a 2022 federal lawsuit (Lange v. Houston County) against an employer plan’s exclusion of gender-affirming care, setting a precedent that such exclusions violate Title VII of the Civil Rights Act. This ruling strengthens FGAS coverage prospects in employer plans.
• Action: Check with your HR department for plan documents or transgender care benefits. Request written confirmation of FGAS coverage.

Challenges in Georgia

• Cosmetic Classifications: Nationally, 51% of commercial policies and most Medicaid programs (except a few states) deem FGAS cosmetic, leading to denials. In Georgia, this varies by insurer and plan.
• Historical Exclusions: Georgia Medicaid historically excluded “transsexual surgery” as experimental (1992 policy), but the 2022 settlement overturned this. Some commercial plans may still have outdated exclusions.
• Appeals: Denials are common but can be overturned. For example, appealing with documentation from surgeons and mental health providers can leverage federal laws (ACA Section 1557) and Georgia’s updated Medicaid policies.
• Limited Providers: Few surgeons in Georgia specialize in FGAS, so you may need out-of-network coverage or travel (e.g., to Atlanta or out-of-state providers). Insurers must cover out-of-network surgeons if no in-network option exists.

Steps to Secure Coverage

1. Review Plan Documents: Obtain your “Evidence of Coverage” or “Certificate of Coverage” from your insurer or employer. Look for exclusions like “cosmetic surgery,” “gender change,” or “transsexualism.”
2. Contact Insurer: Call member services (number on your insurance card) to confirm FGAS coverage, specific procedures (e.g., rhinoplasty, thyroid chondroplasty), and requirements (e.g., prior authorization, letters).
3. Consult a Surgeon: Work with a surgeon experienced in FGAS, such as Dr. C. Carson Huynh at Radiance Plastic Surgery in Atlanta. They can provide documentation and navigate preauthorization.
4. Gather Documentation:
   • Letter from a mental health professional confirming gender dysphoria and surgical readiness (WPATH-compliant).
   • Physician notes documenting hormone therapy (if applicable) and medical necessity.
   • Surgeon’s letter and photographs showing facial features misaligned with gender identity.
5. Appeal Denials: If denied, file an appeal within 180 days, citing medical necessity, WPATH standards, and federal/state anti-discrimination laws (ACA Section 1557, Title VII). In Georgia, 72% of appeals to state insurance departments succeed. Contact the Georgia Office of the Insurance Commissioner (800-562-6900) or file a complaint at marketconduct@cms.hhs.gov.
6. Seek Advocacy: Organizations like the ACLU of Georgia, Transgender Legal Defense & Education Fund (TLDEF), or Georgia Equality can assist with appeals or legal challenges.

Financial Alternatives

If FGAS is not covered:

• Out-of-Network Coverage: Request a Letter of Agreement (LOA) to cover an out-of-network surgeon as in-network if no qualified in-network provider exists.
• Grants: Apply for funding from Point of Pride, Jim Collins Foundation, or TransMission Program.
• Crowdfunding: Use platforms like GoFundMe if comfortable sharing publicly.
• Medical Loans: Explore CareCredit or personal loans, but avoid high-interest options.
• Out-of-Pocket: FGAS costs range from $5,000–$50,000 depending on procedures. Some surgeons offer payment plans.

Georgia-Specific Notes

• Legal Protections: The 2022 Lange ruling and Medicaid settlement strengthen FGAS coverage under federal (Title VII, ACA Section 1557) and state laws. Insurers cannot categorically exclude gender-affirming care.
• Marketplace Plans: Georgia uses the federal HealthCare.gov marketplace. When selecting plans, check for transgender care exclusions and FGAS coverage. Anthem and CareSource are major players.
• Provider Access: Atlanta has some gender-affirming care providers, but FGAS specialists may be limited. Consider surgeons in nearby states (e.g., North Carolina, where Blue Cross Blue Shield covers FGAS).

Recommendations

• Top Insurers for FGAS: Anthem Blue Cross Blue Shield, Aetna, United Healthcare, and CareSource (Medicaid) are more likely to cover FGAS in Georgia if medical necessity is proven. Employer plans from large companies (e.g., Delta, AT&T) are also promising.
• Next Steps: Contact your insurer to confirm coverage, then consult a surgeon with insurance advocacy experience. For Medicaid, reach out to your MCO (e.g., CareSource) and prepare documentation.
• Advocacy Support: If denied, contact Georgia Equality or the ACLU of Georgia for legal guidance. File complaints with the Georgia Office of the Insurance Commissioner or CMS if discrimination is suspected.