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Disappointing insurance news


Hannah Renee

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Unless I am missing something, neither Medicare (primary) nor my BCBS (secondary) will pay for top surgery for MTF, although they will for FTM. Anyone have any experience in this regard?

 

This is really hitting me hard, as these are the only surgeries I can realistically hope - and have planned - to get.

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Some of it will depend on how a referring physician writes up a referral for the procedure.  The term Medically Necessary carries some real weight on the insurance funding.  Your state is not terribly progressive on requiring insurers to cover what are often referred to as elective surgeries, but for us the surgeries are necessary.

 

I would contact your local or at least closest LGBTQ Community Center and see what their members do.  They may have links on scholarships for surgeons in your area, or know of financing options as well.  On our main page there is a list of organizations that help us get needed surgeries. 

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Hannah,

 

What state do you live in? Some states require better coverage. As far as I know, the ACA required insurers to cover gender affirmation surgery back in 2008. Some of the insurers such as United Healthcare will just cover the GAS, but no other procedures as they believe them to be cosmetic. BCBS is usually pretty good in general when you have the proper documentation that you gender dysphoria and letters from a counselor and your healthcare provider. You should call up your insurer and start asking questions. 

 

Sincerely

Katie

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Thank you, ladies, for your input. @Katie23, I live in Illinois, my Blue Cross is the Federal Employee Program (I'm a federal retiree). I called them, then followed up by downloading the most recent benefits. Same answer. Coverage for FTM - mastectomy, chest reconstruction - but nada for MTF. Not certain why one would be considered medically necessary and not the other. Seems somewhat discriminatory.

 

Medicare is rather confusing, as there is not a national policy on specifics. That's left up to regional decision makers.

 

FWIW, from medicarefaq dot com, this:

"Medicare usually only covers transition surgery that alters a person’s primary sex characteristics. But, Medicare won’t pay to change a person’s appearance because Medicare considers it cosmetic and not considered medically necessary.

So, this means Medicare won’t cover facial feminization, breast augmentation, hair removal, face or body contouring, or vocal cord surgeries."

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Hannah, get your provider to file an authorization and reference gender dysphoria. If necessary, file an appeal. Do not let them off the hook. Most of the folks you will take to at any of the insurance companies are typically lay people who have no medical training (I am not making that up). You would be amazed at how little the average customer support rep actually knows.

 

Also check with the OPM (see link: https://www.opm.gov/faqs/topic/benefitsforlgbt/index.aspx?cid=f2dde4b1-d1bf-413f-b3e8-33d46eec6a0c)

 

Remember this, the squeaky wheel gets the oil. I would not hesitate to write to the Rachel Levine, the assistant secretary of health at HHS (see link: [email protected])

 

There is no reason on this earth that one BCBS affiliate should cover the service and another play games. BCBS of Massachusetts covers the breast augmentation:

Directly from the file:

     
     

Chest Procedures

  • Mastectomy and/or creation of a male chest (with or without body contouring) for transmasculine or gender diverse members.

  • Breast augmentation (with or without body contouring) for transfeminine members.

Hormone therapy is not required for transmasculine or gender diverse members requesting surgical chest procedures.

For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is provided under the supervision of a licensed clinician.

 

I have added the MA guide. 

 

I would keep hammering until they cave. Keep asking for a supervisor, and also let them know you are filing a complaint with OPM. That may rattle their cage a little.

 

You may want to also contact your insurance commissioner in Illinois as well as contact your local congressman or senator. Sometimes a quick call from their office seems to make things happen more quickly.

 

It is ridiculous with the hoops and games that are played. This is a difficult time for many folks. If I hear of anything new, I will post it here.

 

Do not give up hope.

 

Sincerely

Katie

 

189 Gender Affirming Services (Transgender Services) prn.pdf

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Thanks, @Katie23, good info. And you should have heard the woman try to pronounce "orchiectomy."

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I can hardly wait to talk to BC/BS about my breast reconstruction. I had really bad gynecomastia when I was 13 years old. Thought the mastectomy would make the "bad" thoughts go away. I got that equation wrong! I wound up with a bilateral mastectomy. According to the insurance regulations, trans or not, I am entitled to a breast reconstruction. This will be one of those priceless conversations. If people had any idea of what we go through. 

 

Hang in there Hannah! If I come across any other stuff you can use, I will forward it.

 

Sincerely

Katie

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47 minutes ago, Katie23 said:

I can hardly wait to talk to BC/BS about my breast reconstruction. I had really bad gynecomastia when I was 13 years old. Thought the mastectomy would make the "bad" thoughts go away. I got that equation wrong! I wound up with a bilateral mastectomy. According to the insurance regulations, trans or not, I am entitled to a breast reconstruction. This will be one of those priceless conversations. If people had any idea of what we go through. 

 

Hang in there Hannah! If I come across any other stuff you can use, I will forward it.

 

Sincerely

Katie

Thanks, Hon, much appreciated.

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This surprises me. 😲 Wth? I can’t for the life of me understand what makes FTM ok and MTF not ok. That’s ridiculous. There’s got to be a way of your Dr says it’s medically necessary due to gender dysphoria I would think. 🤷🏻‍♀️

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39 minutes ago, Vanessa Michelle said:

This surprises me. 😲 Wth? I can’t for the life of me understand what makes FTM ok and MTF not ok. That’s ridiculous. There’s got to be a way of your Dr says it’s medically necessary due to gender dysphoria I would think. 🤷🏻‍♀️

That was my understanding, as well. When my mind is in a little better place, I'll look into it more. Bunch of other things messing with what's left of my brain.

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