Yes, there is bargaining involved. And interestingly, many doctors offices and hospitals automatically reduce the rate for people who are "uninsured" like my family.

Case in point: We took my daughter for some immunizations knowing we would be paying up front for each shot and the doctors visit. The doctor docked 1/3 off his charge for the visit just because we asked and said we didn't have any traditional insurance. We actually asked the Doctor, not the receptionists. When we got to the receptionist to pay for the shots, she rang it up and it was almost $550 for the shots and the doctor visit and asked what type of insurance we had. I told her we didn't have any and she RE-rang it up... $150. Which was what I expected.

The health insurance companies aren't getting a discount...at least at my daughter's doctor's office.

I dont' know anything about gender reassigment. They have their guidelines in a PDF on their site I believe. It goes into great detail about what is not covered. Since it is a Christian based organziation, you can probably assume what may or may not be covered. I just don't know about gender reassignment.