Requesting FFS insurance coverage in Sweden
Getting FFS reimbursement in Sweden is not simple nor guaranteed, but we now have a guide to help you. Thanks to a former Facialteam patient, we can now provide detailed instructions on the process of seeking coverage from Swedish government health insurance for facial feminization abroad.
In November 2021 we’ve held a live webinar with the author of this guide. In this recording she dives into the reimbursement procedure in more detail and answers questions of other FFS patients on the topic.
Who can request FFS insurance coverage?
The Facial Feminization Surgery Reimbursement Procedure Guide was created for trans people in Sweden who have access to the public healthcare system yet plan to have surgery with Facialteam in Spain. However, the advice applies no matter where you plan to have facial gender surgery in Europe.
You must have a Swedish personnummer as a registered citizen, which most residents need to access any care in the country.
Access to Healthcare for Trans People in Sweden
Each region in Sweden has its own gender identity program for adults. The main one is the Center for Andrology, Sexual Health and Transmedicine (ANOVA), located in Stockholm. You will need to go through one of these centers to apply for FFS reimbursement in Sweden.
These are the equivalent of the GIC in the UK or the UTIG in Spain, which offer global medical services for people exploring gender transition.
The good news: In 2010 the Swedish state began a study on FFS procedures.
The not-so-good news. Conclusive evidence of this study is yet to be published. So it is unlikely that facial gender affirming surgery will be integrated in the state healthcare package anytime in the near future.
Unfortunately, there are plenty of steps in this process before you can even apply for coverage of any procedure. This is due to medical providers needing to safeguard from indicating any treatment erroneously that might be irreversible. For this reason, an initial evaluation is conducted that we can break down into 4 basic phases:
- Phase 1: Recommendation Letter
Once a letter from any medical professional is presented, you may expect up to a year before having the first appointment in the “investigation” phase. - Phase 2: Interviews
Various meetings will be required by distinct healthcare specialists to address any co-existing issues that may be present. These appointments may be completed anywhere from 6 months to several years, depending the person and the scheduling. - Phase 3: Diagnosis F64.0
At this point, you are officially designated F64.0: a trans person who is eligible for government medical services such as hormones, fertility assistance, hair removal and surgery. Note that facial gender confirmation surgery is not currently available on the public system, which has lead to exception requests for FFS reimbursement in Sweden. - Phase 4: Life Experience and legal gender recognition
The duration of the life experience requirement may vary from 18 months to two years. Although you can change your name anytime, it is only after this period when you may request to have the legal gender marker modified by the Rättsliga radet. This is the judicial council which provides the document you need before having any surgery.
Applying for your FFS insurance coverage
Unfortunately, since facial gender surgery is not offered by any program, there isn’t an official process. So each center may be different, but the request is likely to be considered an exception.
In any event, you will still have to pay for FFS out-of-pocket initially, as a reimbursement means requesting the state to cover the costs AFTER you have had the surgery. There is a risk of rejection since technically FFS is outside of standard care, but it has been done. Note that the costs of travel, meals, hotels etc will NOT be accepted–only the medical costs.
Försäkringskassan
The Försäkringskassan is the government agency that oversees FFS reimbursement in Sweden, or payments for care that you have not paid for.
Normally you do not have to contact this agency as the gender program takes care of this, but for the FFS exception you will as they are strict about only providing FFS reimbursement if the healthcare was received in a EU country. So non-european countries are not an option if you want to qualify.
There is, in fact, a way to plan healthcare in another EU country in advance (Form: 5421 Ansokan – Planerad vard i ett annan EU/ESS-land eller i Schweiz). Unfortunately, meeting the prerequisite “obtain professional approval” is impossible in the case of FFS since no Swedish medical practitioners will do this at the moment. For this reason, the only option is to pay up front and later apply for reimbursement.
Application process
As mentioned, the process can only begin after returning home from having facial gender confirming surgery. Facialteam will provide you with all the supporting documents you will require, ask for a copy of your file before you leave. The postoperative coordinator can provide further documentation via email if you miss anything.
First, fill in the form 5422 Ansokan i efterhand om planerad vard i ett annat EES-land and make a claim for the amount you have paid (you can do this online on their website). They will ask you for many supporting documents over the course of 2 – 4 weeks as the committee assesses the claim and if you don’t provide these, the funds will be denied.
The Diagnosis codes to use are:
- 2019 ICD-10-CM Diagnosis Code F64.0 (Transexualism)
- 2019 ICD-10-CM Diagnosis Code F64.8 (Gender identity disorders – Dysphoria)
Required documents
Here is a basic list, more details are provided in the guide which the Facialteam coordinator may send you.
- The letter from Rattsliga radet / SocialStyrelsen (the bureau of social welfare) on your application to legally change your gender and get permission to be operated in Sweden (Ansokan om ingrepp i konsorgan, borttagande av konskortlar och faststallelse av andrad konstillhorighet som kvinna).
- Proof of “Frikkort” for both healthcare and medications. (Frikort – Hogkostnadsskydd for lakemedel och Frikort – Hogkostnadsskydd for oppenvard). This refers to the Swedish healthcare entitlement clause when costs supercede a maximum amount.
- Your healthcare journal – (access it via 1177.se) This is proof of the multidisciplinary investigation you will have to show evidence of. You should reference and mark pages where the distinct health professionals you have been in the care of have mentioned facial dysphoria or FFS.
- Lakarintyg (Medical certificate) from the Facialteam.
- Surgical report from the Facialteam.
- Quote from the Facialteam
- Full Invoice from the FacialteamThe amount shown should match the amount of your claim. It should be the itemized list with the details of every costs.
- Balance Due Receipt from the Facialteam and Proof of payment (from your bank)
Finally, you will need a a solid letter to accompany these documents which makes your argument.
Defending your claim in a letter
Despite gathering each and every justifying document, the claims committee will still deny your FFS reimbursement application for two main reasons:
- A lack of scientific evidence proving feminizing facial surgery is effective. This is not true as Facialteam itself has published over 23 scientific publications in leading medical journals and WPATH’s Best Practices also mentions it. Facialteam can provide you a letter to annex which counteracts this point.
- You did not undergo a multidisciplinary investigation by SocialStyrelsen. This is false of course, but you have to prove it specifically for the face with reference to your healthcare journal. The key here is pointing out all the professionals you saw during the investigation phase that mention your facial dysphoria and hopefully even recommended FFS procedures as a solution.
Travelling to Spain for Facial Feminization Surgery
There are FFS providers around Europe of varying degrees of experience. Although Sweden is one of the safest and welcoming places for LGBTIQ+ people, with state services that consider their healthcare needs, many still travel abroad for ffs surgery in other EU countries with the most experienced professionals.
The author of this guide, who wishes to remain anonymous, states, “Based on personal experience, discussions and feedback from peers, the Facialteam located in Spain is regarded as one of the best, if not the best, place to perform a Facial Gender confirmation Surgery…I can vouch for the quality of care and the results.”
The Ins & Outs of Traveling Abroad for FFS Surgery
Takeaway pearls
In conclusion, it is possible to get reimbursed but it is tricky and will take months. You should be eligible for the exception rule if all the above advice is followed and you advocate for yourself along the way. Here is a summary of all points:
- Be registered in Sweden. Being a citizen is a plus.
- Have gone through the investigation process at ANOVA and obtained the “diagonis” of “transexualism”.
- During the whole investigation, you should clearly state that you have dysphoria with your face, want facial gender affirming surgery and keep asking for help regarding it.
- You should have asked for genital gender affirming surgery and received the approval already from Raattsliga raadet.
- Unite all the required documents mentioned to send with your claim.
- Fight to get it done.
Disclaimer
The guide is not an official document, only the process as relayed by personal experience, so outcomes may vary as circumstances and laws change over time. The person who put this together has done this only to help others and was not compensated in any way. This is an abridged version. Ask Facialteam for a complete version.
Hello world! I’m Lilia Koss and I use she, her, and they pronouns. What are yours? With a background in humanities and diverse professional experiences, I have been working with the Facialteam founders and directors since 2008. Involved from the ground up, so I’ve had hands in many pots: patient coordination, orientation events on 3 continents, social media, written and audiovisual content about our gender-affirming healthcare...but now life is more defined. Lately, I focus my energies on Public Relations, community management and live streaming to help raise the visibility of trans health. Life is pretty complete.