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.
Because top surgery is such a specialized procedure, as long as your insurance is in-network with our facility (Norwalk Hospital or Stamford Hospital), your top surgery will be processed in-network, with your in-network benefits applied for all portions of surgery including the surgery, facility and anesthesia. This is true even if Dr. Chandler may be out-of-network with your plan. 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. You have commercial insurance (ex. Aetna, Cigna, United Health Care, Oxford, Blue Cross Blue Shield, Anthem)
This is one of the most common situations for our patients. Many commercial insurance plans include out-of-network benefits, and if that is the case, your costs for the surgery are based on your in-network benefits for all fees related to the surgery as long as your insurance is in-network with the hospital where surgery takes place (Norwalk Hospital or Stamford Hospital). This is true EVEN IF Dr. Chandler is out-of-network with your plan, because of our relationship with the in-network facility. In these cases, surgery with Dr. Chandler is typically very affordable—often the same cost as having surgery with an in-network surgeon, so there’s no financial disadvantage to choosing our practice.
Your insurance will still need to approve your surgery, and we’ll guide you through every step of that process. Approval is based on your plan’s medical criteria, which are usually similar to WPATH guidelines, though each insurance company has its own policies. You can review these criteria on your insurance company’s website or by calling them and asking about their gender affirmation surgery medical policy—and we’re happy to help you navigate this if needed.
If your plan includes out-of-network benefits, we typically have no problem obtaining insurance approval as long as we have a letter of support from your mental health provider and you meet the criteria. However, if your plan does not include out-of-network benefits, we may need to request what’s called a “gap exception” or “network deficiency exception.” This allows your insurance to treat Dr. Chandler as if she were in-network, but it can sometimes be more complex. Your primary care provider may need to send a referral, and occasionally your insurance will require you to rule out in-network options before approving the exception. We’ll do everything we can to support you through this process and make it as smooth as possible.
Scenario 2. Your insurance does not cover top surgery (policy exclusion)
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 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. Please note that if you have another insurance as your primary and Husky as your secondary, the surgery will still be covered at 100% but may be cancelled or delayed if we fail to obtain an approval for the primary insurance. We are required to obtain approvals from all insurance companies.
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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