My Employer’s Self-funded Plan Denies Gender-affirming Care. Can it be Contested?

Hey folks I’ll try to be as clear & concise as possible, but please let me know if additional details are needed.

Going to start by saying that I’m feeling really hopeless at the moment; like the rug has been pulled out from beneath me. I’ve been with my employer for almost a decade because until fairly recently, most things were going smoothly; however, ever since we got a new CEO, work conditions have gone downhill fast.

I began HRT almost a year ago. Our previous insurance plan didn’t cover gender-affirming surgeries, but I was able to get on HRT with little pushback. Now, this year has been an absolute nightmare. Not only did I have to fight HR to maintain my ability to continue HRT, but I was charged for a recent doctor appointment I had. It was just a general checkup with my in-network doctor, and we discussed my transition and how it was going smoothly; no big deal. Apparently, the claim was coded to the insurance company as relevant to my transition, and with key words indicating that. As a result, I was billed $177 for a 25-minute checkup that was no different from any other appointment I’ve ever had in my entire life. I’m still picking my jaw up from the floor; just absolutely floored by this level of dehumanization.

That aside, I requested a coding review and explained my plight to the clinic’s financial department. I’m not anticipating it to change per se, but I refuse to not fight this insensitivity. I intend to discuss this issue with HR this week, but I want to ensure that I have my facts straight before I stick my foot in my mouth and potentially face corrective action. What can I do or say, if anything, that would make my employer reconsider their policy? I live in WI, and from what I can tell, gender-affirming care seems to be protected here; though, I don’t know how far this extends to self-funded plans. Insurance is privatized, correct? I recall HR saying something like, “it’s normal and acceptable for companies to pick and choose what is covered on their plans,” but wouldn’t this fall into discrimination-territory? I have a verifiable diagnosis, so how is it possible for a company to legally discriminate based on that information? They have, at this point, made it functionally impossible for me to see my doctor. My transition cannot be separated from the rest of my being; the subject will inevitably come up in conversation with my doctor, but how can I protect myself from incurring astronomical fees for basic care?

I know that’s a lot of questions, but I’m feeling really lost & hurt right now. I threw out an application elsewhere just in case, but I don’t want this to be the reason why I have to leave a job that I enjoy despite the rest of this garbage. Any help at all would be most appreciated, and thank you to anyone who bothered to read all of this.

submitted by /u/ArcadeSummers
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