FAQ about Self-Funded Insurance

What is self-funded insurance?

Self-funded insurance means that your company has decided to assume financial responsibility for its employees’ insurance claims. Instead of buying insurance through another company (e.g. BCBS) who assumes all of the risk for any claims incurred, your employer will be responsible for funding all insurance claim costs over the plan year. Whether its employees use $5,000 or $500,000 worth of benefits, your company is responsible. This is why it is called a self-funded plan.

Why does my card say I have BCBS insurance?

Your employer has hired BCBS to administer its plan. It acts as a third party between you and your employer. Your claims will be submitted to BCBS for processing and then your employer will be responsible for paying them. This also allows you to access the entire BCBS network of providers.

Does this impact my coverage?

No, and maybe. Insurances offer many different types of plans (even among traditional plans that they fund). Depending upon which plan or plans your employer offers, you may have differences in copays/coinsurances and deductibles. However, that would be the case whether this was insurance-funded or self-funded.

That being said, self-funded plans have historically allowed employers to exclude certain coverages (e.g. gender affirming care) as they were not held to the same standards as commercially available plans. Self-funded plans are regulated under federal requirements so even if the state requires insurers like Carefirst BCBS to offer certain coverages, Carefirst-administered plans may not. However, federal regulations continue to evolve, the DOJ has filed an amicus brief specifically on gender affirming coverage for self-funded plans, and several rulings (including one in a Baltimore Federal court) have found that denying gender affirming care violates the Civil Rights Act. That being said, it is best to check with your insurance plan documents to better understand what is and isn’t covered as gender affirming care is only one example.

How do I appeal a coverage denial?

Typically any appeals are handled by the plan administrator, i.e. the insurance company. However, if the appeal is based upon a plan-wide exclusion (e.g. your employer has elected not to cover a certain brand of medication in their formulary), that could potentially be up to the employer to decide if they are going to pay for an exception outside of what they have contracted with the plan administrator.

What about confidentiality?

When an employer chooses a self-funded plan, they are still required to comply with HIPAA regulations. However, some employees within the organization may have access to other employee’s protected-health information. Confidentiality concerns also depend on the size of the company and how unique your identifying information is compared to other employees. As employers review de-identified data on their plans, it may still be easy to connect this data to an individual (e.g. if you are the only employee who is a parent, when your employer pulls data on expenses related to well-child visits, it will be clear that your child incurred those expenses).

How else might this impact me?

Since the claims processing and payment process is complex, typically Carefirst Administrators claims take longer to process (we average 2-3 months). This means that we may not be able to definitively determine your copay/coinsurance and deductible until that time. Please be sure to review your plan documents or call your insurance to verify your financial responsibility.

Let’s Make Some Room on the Road: Supporting Maryland HB13

In the suburban New Jersey town where I grew up, getting a driver’s license was a rite of passage.  It meant freedom, independence and having to drive your siblings to do their errands.  Though more and more young people are moving to urban environments, eschewing car ownership for ride-sharing apps, getting a driver’s license still remains an important rite of passage for many.  For some people it might even be the only legal record documenting who they are.  Transgender people and those born with an intersex condition or difference of sexual development (DSD), face challenges when documenting their sex on both state and federal forms.  These forms typically only include binary male or female categories, which fail to recognize the variations present both in physiological sex markers (e.g. genitals, internal organs, hormones, genetics) or in neurological aspects of sex (e.g. gender identity).  The process of changing them is often costly and time consuming.

On Thursday, the Maryland House Environment & Transportation Committee heard testimony from legal advocates, medical professionals and community members in support of a bill, Maryland HB13, which would create an “unspecified” option for sex markers on Maryland State driver’s licenses. Similar changes have already been made in other states, including neighboring Washington D.C., a point driven home by Dr. Dana Beyer, representing Gender Rights Maryland.  My colleague, Dr. Elyse Pine, a pediatric endocrinologist at Chase Brexton, spoke to the socially constructed nature of natal sex and encouraged the committee to consider that, for many people with intersex conditions/DSD, having a non-binary sex category would be a better reflection of who they are.  The same is true for transgender individuals who identify as non-binary and present themselves as such.

In addition to echoing the above points, my testimony also spoke to the challenges that researchers face when trying to conduct research on populations who are not able to identify themselves accurately.  For example, when I served on Chase Brexton’s Diversity Committee, one of our goals was to find a better way to document trans* and non-binary identities in our electronic medical record.  Our inability to search for our patients using non-binary categories prevented us from a) describing our population accurately, b) identifying people who would be candidates for tailored health interventions, and c) conducting outcomes research, some of which is required by federal regulations, accrediting bodies and/or grantees.  My colleague, NP Jill Crank did a yeoman’s job in calculating numbers based on a manual review of diagnoses… but researchers and practitioners need others (e.g. governing bodies, insurers) to join us in creating more accurate ways to define and collect both sex and SOGI (sexual and gender identity) data.

Changing the way we record sex and gender data on state licenses, adds momentum to the already evolving way that scientists, societies and individuals understand sex and gender, and creates more room on the road for both intersex and transgender individuals.  I support this bill and hope to see it move forward.

Read more about the bill and my testimony in this Washington Blade article.

Finally, I would like to thank Alesdair Ittelson from InterACT and the Intersex and Genderqueer Recognition Project for consulting with me on my testimony.

Why I Don’t Support Gender Policing in School: Part 2

Part 2: How I Realized I Had No Idea What Sex Was and Neither Do You

It was my final year at Johns Hopkins University and, like many other seniors, I had no idea what I was going to do with my life post-graduation.  I was, however, pretty confident about certain truths.  For example, I knew that while Harvard curved to a B, JHU curved to a C (which meant we were smarter and it was thus fine that we didn’t get into Harvard).  I also knew that you could interoffice loan articles so that instead of walking (gasp) all the way to the library, you could get someone else to scan them and e-mail them to you.  And I knew that biological sex, i.e. male and female, was an innate binary reality, because, of course, why would it not be?. However, all that changed when I began working with my professor, mentor, friend and fellow zooborns aficionado, Dr. Amy Wisniewski.

At that point in my training, I had already realized that research on neurological sex and sexuality differences was fraught with sampling bias and threats to both construct and content validity.  After running straight and gay men and women through a maze for a research class I discovered that my straightest-brained straight man had been making out with another man at a party.  I started to question the results, not only of my trial, but of other studies on so-called “gay” brains.  How could one be certain that the brains we were researching accurately captured the brains of our population or of the behavior of interest?  Were the brains of women and men, let alone heterosexuals and LGBTQ people, even all that different in the first place? None-the-less, I was still pretty certain that, even if gendered brains weren’t all that real, sex was pretty clear.

Enter Amy.  Amy had been conducting research alongside Claude Migeon, an endocrinologist with a thick French accent who had been practicing literally since the endocrine system was discovered and who was best known for his work on congenital adrenal hyperplasia (CAH).  We briefly discussed this health condition in the Human Sexuality class Amy taught and I was eager to learn more.  It was from this space of curiosity, that I entered her cramped office in the Park Building above the old Children’s Center.  Two years later I left it entirely changed.

CAH occurs when the body is missing an enzyme (there can be several types missing but it is typically one called 21-hydroxylase (21-OH).  21-OH is necessary for the production of cortisol.  Often called the “stress hormone,” our body produces cortisol not only to deal with physical and emotional stress but also to help regulate aspects of metabolism.  When our body isn’t getting enough cortisol (including when we are developing in the womb), it turns on the adrenal glands and tells them to produce more of the building blocks or pre-cursors to cortisol.  These then get assembled or synthesized into the finished product.  However, if one of these building blocks is missing or can not be produced, as is the case with individuals with CAH, the body keeps producing the other pre-cursors since it doesn’t know when to stop (i.e. the feedback loop is broken since no end product is ever developed).  As this process continues, the other precursors and the hormones that are made alongside those precursors build up to elevated levels.  For individuals with CAH, this includes androgens.

Exposure to hormones  (like androgens) play a role in shaping our internal and external reproductive structures while we are still developing in the womb.  Our organs start out looking the same and then change shape and grow in various directions in response to the hormonal milieu around us.  Most people are familiar with terms like penis, clitoris, vagina, scrotum and see these as very different organs… but, really, they start out the same.  Like pasta, a basic dough can be used to make a wide range of shapes.  Also like pasta, there is a wide degree of variation across brands, errr… body parts.

This became increasingly clear to me as I learned more about CAH, intersexuality and about sex in general.  It turned out that I actually couldn’t prove my own sex with certainty.  I had never had my chromosomes tested so how could I know what category they fit into without seeing them?  I wasn’t even sure we had enough categories; if 46,XX chromosomes were labeled female and 46,XY were labeled male, where did we put 47,XXY or 45,XO?  Clearly, genes alone weren’t enough to categorize sex.  But maybe genitals would be better?


As I would come to find out, genitals also weren’t always reliable for  categorizing bodies.  For people with CAH who have 46,XX chromosomes, that additional prenatal androgen exposure changes the way their genitals develop.  And it doesn’t just make “girl” bodies into “boy” bodies; that would be way too binary.  Genital shapes really are more of a spectrum (even for people who DO neatly fit under a specific socially-agreed upon sex category).  For people born with a difference of sex development (DSD) or who might identify as intersex this might just be more apparent.

But, for arguments sake, let’s say that you could ignore the fact that a person doesn’t know their chromosomes.  And let’s assume that you think that your body looks pretty binary from the outside.  How could someone still possibly question their sex?  Well, most of us have never seen our internal organs and certainly few of us have had them biopsied to be sure that the tissue inside a thing that looks like a testicle actually is testicular tissue, for example.  Working with Amy and Claude, I learned that even internal organs can vary and that the ways these organs function is also contingent on both internal hormonal levels as well as external factors like stress, overall health, exposure to toxins, etc.  The argument that sex was binary and that someone could even presume to know someone else’s sex just by looking at them was crumbling before my eyes.

So, if “sex” as we know it isn’t a discrete category and, in reality, the average person does not know what anyone else’s chromosomes, genitals or internal organs look like… what does that M or F mean on our driver’s license?  The answer?   It’s actually your gender.

Though most people are raised as a certain gender based on their sex assignment at birth and we thus assume that gender is rooted in sex, the reality is that, in day-to-day practical application, we know VERY little about the sex of the people we interact with. Sure, there are a few hints to go off of… like secondary sex characteristics (i.e. facial hair, voice pitch, body-fat distribution) but there is a wide variation in how people look and groom themselves, so that’s not always reliable.  For the most part, we rely on someone’s gender presentation to make inferences about their biology, not the other way around as bathroom bills would have it.

For example, when I show up to the MVA to get my license, I bring a tattered and faded piece of paper that is nearly four decades old and from a different state, and that was filled out by someone who I (let alone the clerk sitting at the MVA window) never met.  In fact, there is nothing to have stopped me from having printed that out myself.  However, the clerk never questions me.  Why?  Because the way I dress and style my hair matches that M.  That is, of course, my privilege as a cisgender person, but it also highlights the reality that our judgments about someone else’s sex are largely dependent upon the evidence those people put before us rather than some innate truth about bodies.  Furthermore that evidence is dependent upon the norms that any given society or societal subset determines to be masculine or feminine, all of which is subject to change.

When it comes to bathroom bills and other gender policing efforts, unless we are all willing to have our mouths swabbed to test our chromosomes and submit to a physical exam and ultrasound, and then wait several days for the results, we will never be able to know the sex of anyone else in the stall next to us.  Instead, we will have to trust that people know what bathroom they belong in and continue to prosecute bathroom-related crimes the same way we do now, regardless of the gender expression of the person involved.

Why I Don’t Support Gender Policing in Schools: Part 1

Part 1: I’m Not a School Psychologist but I Play One On TV

A close friend of mine from graduate school always teases me about being a School Psychologist on the down-low.  Though my training is in Counseling Psychology, for the bulk of my career, in addition to adults, I have also worked with children and families, and my research has focused on sex and gender across the life span.  Looking back on my degree program, all the early signs were there.  In lieu of taking additional multivariate statistical coursework I elected to take psychometrics (in layman’s terms, school psychologist math).  I took my dissertation prep class with the school psychology students instead of with my counseling cohort.  I even ended up with a postdoctoral fellowship in Pediatrics.

As such, it was both an honor and a sort of long-lost homecoming to be invited to conduct a half-day workshop at this year’s National Association of School Psychologists (NASP) annual convention in San Antonio.  I had worked with NASP previously on a series of articles on sex development, including an interview with two intersex youth advocates, for their publication, the Communiqué, so was familiar with their position statement on transgender and gender non-conforming youth.  I also knew that NASP convention organizers highlighted trans issues last year including having Janet Mock as their keynote and offering a workshop by Dr. Colt Keio-Meier .  NASP, as an organization, was ahead of the curve when the Departments of Justice and of Education provided guidance on applying title IX for transgender youth including bathroom use in school settings last Fall.  With all this in mind, I imagined we would be having a very different discussion than in the past and proposed the workshop title “It’s Not Just Bathrooms: Supporting Students’ Gender Identity and Expression.”

SPOILER ALERT: It’s about bathrooms.

I spent the bulk of the weekend in Austin, visiting my stepbrother and trying to enjoy as much warm weather as possible (it is still technically winter back home in Baltimore though I heard it was in the 70s while I was gone – thanks global warming).  On Monday morning, I made my way to San Antonio, got lost on the Riverwalk with a colleague, then spent the time before my session in my hotel room prepping the last of my presentation and ironing my clothes.

Tuesday afternoon there were just shy of forty people in my workshop.  In light of Texas’ bathroom bill legislation proposed for this year, I included a lot more about bathrooms than I originally thought I would or than my title suggested.  I even tried to connect Texas school psychologists with the Texas Association of School Psychologists to encourage them to draft a position statement on the bill.  This seemed important to do given the Texas Psychological Association’s silence on the matter.

We were mid-way through the workshop when I heard the news.

Typically when I present, I try to engage the audience in exercises and role-plays.  It was during one of these moments, as I was walking through the aisles, that one attendee pulled me to the side and showed me something on his phone.  It was a news article about the current administration’s withdrawal of guidelines for transgender youth in school settings.  I couldn’t even take it all in at that moment; I was not surprised but somehow was still shocked.  I supposed that it was only a matter of time.

I wrapped up my presentation that day, highlighting the complexities of creating safe(er) spaces for gender expression in school, trying to pull out the nuances and emphasizing that this can’t be a one-size-fits-all solution, and hoping the people in the room would leave with a desire to advocate for their students.  I tried to answer as many questions as I could and, as is customary once people start getting into the nitty gritty of implementing supportive policies, we ran out of time.  To that end, I know colleagues here in Maryland who have spent five years trying to get policies in place in their district, yet, somehow, I hoped we would fit everything into three hours.  I left that session feeling energized… but mixed in with that energy were feelings of restlessness and inadequacy, bolstered by the belief that there was so much more that we needed to talk about and so much more that needs to be done.

Though the task may at times seem daunting, our work is entirely based on adapting our universal understandings of mental health phenomenon and evidence-based practices and tailoring them to unique individuals and settings.  Supporting gender expression does not have to be any different than applying our other areas of expertise and is, in reality, a far less daunting task than the one faced by so many individuals expressing their true self in the face of hate, fear, rejection and  violence.  The removal of federal guidance is symbolic and deeply troubling/alarming/concerning/pointless, and places people at risk in states with less supportive climates.  However, as practitioners, we are still capable of following (and, in fact, obligated to follow) our own organizations‘ ethical and competency guidelines.  There is strength in our numbers and in our commitment to providing competent interventions.

There IS so much more that we need to do and so much more that we CAN do.


Up next… Part 2: How I Came to Realize I Had No Idea What Sex Was and Neither Do You

Cultural Competence: What’s the Point?

Originally posted on Dr. Malouf’s LinkedIn page on May 1, 2015

On the heels of a week of protesting in Baltimore city following the death of Freddie Gray (and over 100 police brutality lawsuits since 2011 and decades of racial disparities), I had a reaction to a friend’s friend’s Facebook comment about cultural competence.  Since, I didn’t know that person and typically don’t find semi-anonymous social networking forums the best ways to engage in emotionally charged conversations, I vented to my friends and several of them asked me to share it (see italics below for my initial FB post).

I was frustrated at this person’s comment in part because it was something I hear a lot (often during cultural competence trainings) and seem to never be able to address enough… the belief that “cultural competence” is just some trendy idea that is secretly political correctness, repackaged, and therefore not worth learning about.  In my experience, comments like these have typically been uninformed, have often been dismissive, have never been followed by an alternative proposal for improving interactions between people and usually completely miss the point of cultural competence. And yes, I get it… we’re all jaded from sitting through ineffective “diversity trainings,” and being sensitive to others when you’re already burnt out is challenging, and acknowledging our own privilege/lack of privilege isn’t always comfortable… but that doesn’t mean cultural competence should be thrown out with the proverbial “diversity initiative” bathwater. To help folks understand that the following aren’t interchangeable…

“Political correctness” = you don’t change your views about some other group of people, you just learn when and where not to say them and what people might disagree with you if you say them out loud. The goal is for people to like you for not being biased.

“Appreciating diversity” and “diversity training” = you may or may not change your views about some other group of people but you learn lots of facts about the group in general and ways to interact with them. The goal is for you to like yourself for not being biased.

“Cultural competence” = you change your views about YOURSELF and acknowledge the ways your own culture might impact what you currently know about other cultures, and, more importantly, what you’re going to come to know about other cultures in the future and how you’re going to interact with other individuals irrespective of their culture. The goal is to interact better with people who aren’t like you because you acknowledge your biases… regardless of whether others like you, you like them or you like yourself.