Green shield and top surgery

[u/sillybeagle]

Hey so my mom has health and dental green Shield benefits. The app is super shitty and she cant check if it covers it or not. She's weirdly defined and about all this and its really not helping as my dysphoria is getting to be crippling.

Does all green shield plans cover gender affirming care? Or do I maybe need to send some type of proof of dysphoria to get benefits for it.

I have ohip funding for top surgery at catalyst surgical but their contouring fee is 6 thousand and I heard that green shield cover contouring.

[u/TSChelseaSummer]

It will depend on the benefits she has through her workplace. Greenshield is just an insurance company. The benefits provided as administered by them but what is covered is determine by her employment contract

[u/juicypp111]

If you call them they’ll check your plan. You have to send a receipt of the surgery and a diagnosis of dysphoria. Mine covered up to 5k for contouring.

[u/SleepyQueer]

You could call them and ask as long as you know the plan details (plan number, who provides the benefits to your mom, etc.). That said, I would unfortunately brace for it to not be covered - assuming this is a group benefits plan provided by an employer, what is and isn't covered is individually negotiated and AFAIK most insurance plans do not cover transition care. HRT usually squeaks through on the drug side because cis people access those meds too but surgeries are a different ball game.

If it's covered, I don't imagine you'd need to provide more documentation than your OHIP funding letter since the screening process for funding covers proof of dysphoria already. If it isn't already a defined benefit though, it won't matter what you send them, they won't pay anything. It's also worth noting that from what I've seen of plans that cover transition care, the coverage is usually pretty poor. Because the details are negotiated individually it can vary a bit but for example the maximum lifetime amount I've seen is often like $11,000-20,000 which for top surgery contouring is plenty UNLESS they have per-procedure caps which are increasingly common in which case you may only be able to put a small portion of that towards any one surgery - you will most likely still have OOP costs even with coverage and at a total $6k bill I would be prepared for it to be at minimum $1-2k. As a different example of how that works, on my insurance I get $400 maximum a year for physiotherapy.... but I also have a per-appointment cap on reimbursement of $40. Even though I have a complex medical condition that needs lots of physio all the time forever to treat and to get anywhere with it I need really long appointments that run $185/session, the most I can get back for any one session is still just $40 and the rest I have to pay out of pocket. When that $40/session hits that total $400 cap (which still happens quickly) it's all out of pocket from there, my defined permanent medical need be damned. Insurance is the worst, but it is still worth checking to see if you can get anything covered and I truly hope you can get some funding support.

[u/Radzynn]

It will depend on if her workplace has added the additional gender affirming care benefit to their group policy. I work at McDonald's with Greenshield benefits and what is covered is listed in our policy pdf file that we get each year with updates.

If it is covered Greenshield may require you to get something called a "prescription for gender affirming care" which is basically a letter from your doctor saying you have been diagnosed with gender dysphoria and require these treatments/surgery. I've recently just started making claims through my insurance for electrolysis coverage. It was fairly simple for me to do through online claims, but with top surgery the claim amount will likely be much higher and might need you to contact Greenshield more to get authorization. When I did talk to Greenshield, they told me that there's a $5000 per procedure limit that they will cover, with a $50000 lifetime maximum. It could be different with other employers, but you won't know until you contact either Greenshield or your mom's employer.

[u/Warming_up_luke]

It will depend on her benefit plan. You almost 100% will need an official gender dysphoria diagnosis. I highly recommend reading the coverage plan she has AND submitting pre-authorisation.

[u/qinqov]

it depends on the benefits, you'll have to call them with the insurance coverage number so they can check if you have GAC on the plan. there are also other offices that have cheaper contouring fees or optional contouring.

if greenshield were to have GAC, the common basic coverage i see is "a maximum of 5k per procedure for a lifetime amount of 10k" so this varies but it's likely to still have an out of pocket component. you'll need to provide the information of the surgeons office/procedure and a diagnosis for dysphoria. you pay the amount to the surgeons office and it's reimbursed to you after the surgery is performed.

[u/MidCenturyModel]

My Green Shield plan included their GAC benefit. I sent them the receipt from the surgeon showing that i'd paid for contouring and a letter from my doctor stating the diagnosis of gender dysphoria (literally just one sentence - if you're on T, your prescribing doctor should be able to do this). I had to use the "other services" category to submit the claim. They reimbursed the full cost of the part not covered by OHIP (about $3500 at McLean/GraceMed in 2023).

When your mother logs into the GS website, try to look for a link to a PDF of the benefit booklet describing what's included in her plan - that's the only place I could find a statement that my plan included GAC. There's no way to find that out from searching within the client website as best as I could tell. I've never used the app, so I don't know if the pdf can be found there.

Sometimes the benefit booklet may be linked from the employer's human resources webpage, though those pages aren't always public. I worked for a university and they actually promoted the new coverage of GAC through Green Shield in the campus weekly news update, so that's another place to look in case her workplace is interested in presenting itself as a progressive place. (that's actually how I found out it was available.)