Medicare plus Supplement vs. Medicare Advantage

[Jacqui]

Does anyone have any experience or thoughts regarding whether there is any difference in how these options determine the 'medical necessity' of transition procedures?  Would one option be easier to convince of medical necessity than the other?  For that matter, would certain Medicare Advantage providers (UHC, Anthem, Aetna, etc.) be more 'transition friendly' than others?

 

Apart from things like co-pays and out-of-pocket maximums, Medicare Advantage plans are supposed to (at minimum) cover the same things as Original Medicare.  Both will cover transition items if deemed "medically necessary".  However, Medicare Advantage plans have their own administrators (outside of Medicare) who would weigh in on this determination.

 

To make things more complicated, I believe the administrators for both Medicare and the advantage plans are regional.  (To help this discussion, I live in Wisconsin, and so would be particularly interested in your experiences with the options, carriers, and administrators in my beloved Dairy State.  )

 

I won't be too disappointed if this topic draws no responses (due simply to lack of available information on everyone's part).

[Jani]

My understanding is the Advantage plans are separate and distinct from Medicare.  That said they are like pre-medicare plans in that each has its own limitations and costs.  You really need to deeply investigate the plan you are interested in to determine what is exactly covered (or not).

 

Jani 

[Dana Michelle]

I live in California and I have a Medicare advantage plan through Kaiser Permanente that covers the full cost of electrolysis, facial feminization surgery, breast augmentation and genital surgery. Prescriptions cost me $1.20 for a 100 day supply. The monthly premium varies each year, but I think the most I've had to pay is around $7 and currently pay $0. I don't have any co-payments or deductibles (except the $1.20 co-payment for prescriptions).

[Jacqui]

Thanks for your replies.  @Dana Michelle, from what you and others  (in other topics) have said, California is sort of an 'Eden' for transitioning folks, with Kaiser Permanente being particularly generous in all that it covers.  Sadly, Kaiser Permanente is not available to me in Wisconsin (at least in terms of advantage plans).  I suppose they are also easy to convince of the 'medical necessity' of transitioning.

 

@Jani, I was not asking about coverage per se, but rather about the ease of convincing them of the 'medical necessity' of transitioning.  A plan may cover many medical procedures that are a part of transition, but may reject a particular set claims on the grounds that for a given individual, transitioning is not "Medically Necessary".  (I suppose that would mean that a given individual does not suffer sufficient distress from gender dysphoria to warrant paying for transitioning.)

[Jani]

You would need to investigate into that once you determine if they cover your needs by calling the Plan to inquire.  This entails outing yourself to them which may be dysphoric. 

[Jacqui]

@Jani, I was hoping that someone else from Wisconsin might have already done what you describe so I could benefit from their knowledge and experience without "outing" myself.

 

Right now I'm trying to decide if I should out myself to them to get some insurance coverage for the gender therapist I'm planning on seeing.

 

[Lexi C]

Hey I am on MediCal through the Affordable Health Care Act (AKA Obama )

I would be lie if i didn't say there's a lot of hoops to jump through. Because even thought I am on MediCal my  provider or IPA is Health Care L.A. and to be honest they are either constantly fighting me or each for care and cost.

Exp.

I was ok for bottom surgery through H.C.L.A but Medical was saying they never received a referral. I finally (after 15months of fighting) got a referral to have a consult ( not the actually procedure) with Dr. Garcia. Whose office has inform me that if I qualify that i most likely have to wait another 1yr to 16 month for the actual procedure, that H.C.L.A said i qualified for over 2yrs ago. 

Maybe t's Ceder Sinai which is were all my procedures are schedule thats the problem . Regardless , I pay not cost for any surgeries, office visit , drugs . I only pay for my TG therapist.

 

 

 

 

 

 

[Jacqui]

Thanks for the info, @Lexi C.  Sorry to hear about some of the tribulations you faced.  Happy for you that so many of your costs are paid for.

[Lee H]

2 hours ago, Jacqui said:

I was not asking about coverage per se, but rather about the ease of convincing them of the 'medical necessity' of transitioning.  A plan may cover many medical procedures that are a part of transition, but may reject a particular set claims on the grounds that for a given individual, transitioning is not "Medically Necessary". 

Hi Jacqui

I enjoy reading your posts -- thoughtful. Here's another thought: Maybe learning all you can about how to succeed with the totality of the paperwork you present would be effective. Someone in your medical insurance hierarchy needs to make a decision. Their primary goal is to avoid getting hassled by their boss; you are just a set of forms on their desk. I doubt they will interview you. Too risky for them. So rather than your assuming the burden of convinc[ing] them of your "medical necessity," perhaps your task is discovering what should be in the package of paperwork the memos they've gotten from their boss[es] instruct them to stamp, "approved." Ie, when do they think it is safer for them to say "yes" than "no?" 

 

If this makes sense so far, the question becomes, what is "safer" for them? First -- your "medical necessity," obviously. That will be diagnosed in a letter from a counselor, not by an unqualified insurance clone. So I'd suggest questions for the counselor, such as, "What works?" "What controversies do they want to avoid?" "What risks are they taking by saying "yes?" And perhaps most informative of all, "What is your track record with people like me, Doc?"

How do we minimize their risks of saying "yes?" What are their "No" risks? How do we heighten those risks?

 

You know how you feel. You are Jacqui, whether they like it or not. You know what you want to achieve. Whether some clone in a cubicle deep in an insurance edifice agrees or not is utterly insignificant. However, to me, learning what you can about how to "make them an offer they can't refuse," seems like a good move. And I think finding a counselor who knows what such an offer looks like, makes a wholebuncha sense.

 

Onward and upward, dear Sister.

~~Hugs, Leah

[Jacqui]

That's very good advice, @Leah.  Thanks!

[Dana Michelle]

3 hours ago, Lexi C said:

Hey I am on MediCal through the Affordable Health Care Act (AKA Obama )

I would be lie if i didn't say there's a lot of hoops to jump through. Because even thought I am on MediCal my  provider or IPA is Health Care L.A. and to be honest they are either constantly fighting me or each for care and cost.

Exp.

I was ok for bottom surgery through H.C.L.A but Medical was saying they never received a referral. I finally (after 15months of fighting) got a referral to have a consult ( not the actually procedure) with Dr. Garcia. Whose office has inform me that if I qualify that i most likely have to wait another 1yr to 16 month for the actual procedure, that H.C.L.A said i qualified for over 2yrs ago. 

Maybe t's Ceder Sinai which is were all my procedures are schedule thats the problem . Regardless , I pay not cost for any surgeries, office visit , drugs . I only pay for my TG therapist.

 

 

 

 

 

 

I've had issues with Kaiser, such as problems with the billing department, and sometimes it is a hassle to get services. There are times when it has been difficult to pick up a prescription. I've been working on getting FFS since October 2018, and in October 2019 they finally scheduled my surgery for June 2020. Because of the pandemic, surgery had to be postponed and they have no idea when they'll be able to schedule it. It's extremely frustrating to have to wait so long just to get a surgery date, only to have that date pass and still be a long way from getting a surgery date. Recently the surgical team for the breast augmentation wanted to schedule me, but I need to get FFS first since I don't want to look like a man with breasts.

I also had a lot of trouble recently getting my authorization for electrolysis renewed (authorization for Kaiser to pay an outside provider). They said it should be ready in a week. After 1 1/2 weeks when it didn't happen I called back on a Friday and was told I need to call on Monday since the nurse wasn't in. I called Monday and was told the nurse would call me back. When that didn't happen, I called back on Tuesday and was told the nurse that handled the authorization started vacation the previous day (so why was I told to call back on Monday when I called Friday, if her vacation would start on Monday?). They nurse was back from vacation the next Thursday, when to my surprise they authorized the electrolysis.

 

[Lee H]

3 hours ago, Jacqui said:

That's very good advice, @Leah.  Thanks!

My pleasure, Jacqui. Really. I don't know about you, but I'm liking the style of communication I take to be more consistent with the feminine psyche I'm trying to get to know better -- empathetic, caring and loving. Ie, you're Jacqui, I'm Leah, and we can be friends without competing about anything....

~~ More hugs from Leah

[Lexi C]

Hey Jacqui np.

Dana wow..that carzy to hear about Kaiser. Cause i was thinking of switch to them.

Cedar is no better. I guess like Jacqui said, i should be grateful that most all of exp are being cover right now

Dana hope it works. I kinda of dealing with same isuse for both mu bottom and FFS

 

 

 

 

[Jacqui]

2 hours ago, Leah said:

You're Jacqui, I'm Leah, and we can be friends without competing about anything....

 

Um, let's not get carried away, okay girlfriend? 

 

. . . PSYCH!!

 

All kidding aside, @Leah, I agree with you completely.  It's so very nice (as well as soothing to the soul) to focus on empathy instead of ego.

 

I don't know if you saw my initial topic (in the "What Am I . . ." forum), but since you identify here as a crossdresser, I was wondering if you had any thoughts as to why no crossdressers replied to that topic.  I was expecting that at least one or two might feel they had some degree of common experience.

 

Hugs,

Jacqui

[Lee H]

Hi Ms. Jacqui

I dunno'. Maybe some reluctance to acknowledge their own crossdressing has progressed to gender doubting?

Due to every preexisting Covid risk condition known even to Dr. Fauci, I decided in March that I would observe the stay-at-home recommendations as closely as I could. I live alone with my mutt and the collection of bras and panties that had been gathering in my drawer for years. Merely occasional entertainment, I thought. So, I decided, if I'm just here writing historical fiction and playing guitar [my hobbies for decades.] I may as well do it "en femme." I didn't really know what that entailed, and still don't. It was feeling "good," and not limited to briefly arousing any more. My early posts were around the question, "Is this a process? Will I progress further toward femininity?" I noticed how good it felt to communicate in what I take to be a feminine head-space -- open to emotions, empathetic and intending to be friendly to others like myself.

Soooo,

I started reading others' posts, and watching online gender counselors. I especially like "Dr. Z PhD". I'm hearing that it definitely, surely, indeed, bet your whole pot is a progression, and I'm moving from the "manly man" DIY'er toward the "nice" old-as-dirt but young-at-heart woman. Also, Kay, moi copine, and others unanimously recommend counseling, and Kay said she'd heard good things about the VA LBGTQ+ services. So, inasmuch as nothing so far is or soon would become irreversible, I dropped a dime. So far, all women, and very welcoming. My first "intake" type appointment is Tuesday. My impression so far is that gender counselors see us as moving along a continuum, and want to help.

I'm expecting no one to say, "It's just a fetish," and I'm hoping they can find some way I can have HRT, despite all the other stuff wrong with me. My hoped for goal is, "A little more feminine every day, enjoying each one of them as its own precious experience." I'm in no hurry, but I am feeling more hopeful anticipation every day, and displaying my female persona, if only to my puppy and that awful, grotesque mirror I have to encounter very carefully. 

Sorry for digressing onto ... um ... my own trip? Not really responsive to your question. But here's a tiny thread of relevance, at least, perhaps something to pull on and see where it's connected -- 

My personal understanding of where I am has progressed from being stuck at the "Crossdresser" station to realizing it was only a lay over, and there's a long journey left ahead. Life long, actually. So the distinction between "cross dresser" and "transgender" for me is dissolving. I feel like I can talk with you girls on this Forum coming from the same place. Obviously I'm a rank beginner, but I'm feeling like I'm playing on the same courts as everyone else. [That breaking glass sound is the forced mixture of metaphors]. 

In my world, "sharing" means telling my own story, what it was like, what happened, and what it's like now. I try very hard to stick to my own experiences and hopes. If I say something you think might be useful for you, great. It's yours, and I'm happy. But if you think what I'm saying is a load of ... um ... irrelevancies, leave it. The journey we're on has its own value, principles and integrity, irrespective of my inability to do it justice.  

So, if this even remotely is relevant to what your were asking, thanks for asking. If not, sorry to waste all those ones and zeros. In any case, can we [still?] be friends? [Are girls that up-front? I dunno', but it feels good to me.]

~~Hugs and squeezes, Leah~~

[Jacqui]

Hi Ms. Leah,

 

Thank you for sharing your experience!  It definitely is useful, if for no other reason than it lets me get to know you better (and learn that you are a caring, intelligent, introspective person who is worth knowing).

 

I have an appointment with a therapist next week, and I definitely think that counseling will be helpful.  First and foremost, a good gender therapist helps a person figure out who they are and what they need to be happy.  Then the therapist helps them get where they want to be.  So the therapist definitely shouldn't be saying "it's just a fetish" (some patients may draw that conclusion on their own during counseling, though).

 

Regarding HRT, with "informed consent", I don't think you even need to obtain a therapist's approval (unless you have significant mental illness).  Then again, if you have physical issues that would make HRT dangerous to your health, the endocrinologist might hold back.  Your gender therapist should have all the information you may need.

 

I always say "if it feels good, do it", and I am definitely a up-front girl, so HELL YES we can be friends, dear Leah.

 

~~Hugs and 'air kisses' on both cheeks, Jacqui~~

[Confused1]

On 8/25/2020 at 8:43 AM, Jacqui said:

Does anyone have any experience or thoughts regarding whether there is any difference in how these options determine the 'medical necessity' of transition procedures?  Would one option be easier to convince of medical necessity than the other?  For that matter, would certain Medicare Advantage providers (UHC, Anthem, Aetna, etc.) be more 'transition friendly' than others?

 

Apart from things like co-pays and out-of-pocket maximums, Medicare Advantage plans are supposed to (at minimum) cover the same things as Original Medicare.  Both will cover transition items if deemed "medically necessary". 

Hi Jacqui,

I am on straight Medicare. They decide on a case by case basis. I tried calling the number on my Medicare card and all they could do was read from a list of what WPATH basically says. They couldn't even pronounce dysphoria. When I asked questions I got transferred to another person who did the same. When I asked a question again, I was told that my provider would have to call them. The only really helpful thing I got from them was that decisions are not made at the state level.

 

The surgeon I plan to use is in another state and the surgeon's office thought that it might be different here than there. I have a Masters level therapist that referred me to a therapist that has an MD license. I already have a letter from the MD and then I heard on another forum that I also needed a PHD level letter for Medicare. After several back and forth conversations  with the MD, I am now working on getting my third letter. Not sure if the right hand know what the left hand is doing, but I did not want to find out right before my surgery is scheduled that I had to wait. I may still have to wait, because after I got my first letter I scheduled a consult in Oct. I talked with someone and sent paperwork yesterday to get started with a PHD Psychologist. They are supposed to get back with me to give me a date

 

As for Medicare Advantage, I have no idea! Amazing the hoops we have to jump through.

 

Mike.

[Jacqui]

Thanks for the info, Mike!

[Mmindy]

On 8/25/2020 at 9:43 AM, Jacqui said:

Does anyone have any experience or thoughts regarding whether there is any difference in how these options determine the 'medical necessity' of transition procedures?  Would one option be easier to convince of medical necessity than the other?  For that matter, would certain Medicare Advantage providers (UHC, Anthem, Aetna, etc.) be more 'transition friendly' than others?

@Jacqui, thank you for asking this question. My wife will be signing up for Medicare this Fall, and I will be next Summer. While my Suzie has no real cares or concerns, I'm full of the same questions you just posed. We live in Indiana and hope it is a friendly experience to work my transition issues through.

 

Mindy???

[Confused1]

10 hours ago, Mmindy said:

@Jacqui, thank you for asking this question. My wife will be signing up for Medicare this Fall, and I will be next Summer. While my Suzie has no real cares or concerns, I'm full of the same questions you just posed. We live in Indiana and hope it is a friendly experience to work my transition issues through.

 

Mindy???

 

Hi Mindy,

 

I have not had surgery yet, but am getting a consult in October. Once I get some idea of how this works for me I will try to come back and post it here. Medicare is decided case by case, whatever that means. I was told by a call I made to them that this decision would be at the Federal level. However, they didn't seem to be able to answer any other question I asked, so take that with a grain of salt.

 

By the way, I was raised in IN! Moved to Arkansas about 30 years ago for my job.

 

Hugs,

Mike

[Mmindy]

2 hours ago, Confused1 said:

By the way, I was raised in IN! Moved to Arkansas about 30 years ago for my job.

Thanks Mike, 

 

My elder family as well as my wife's elder family, lived all across Northern Arkansas. From Corning in the East to Fort Smith and Texarkana in the West. Flat land to the Ozark Mountains, we love them all.  

[Bri2020]

On 8/25/2020 at 7:59 PM, Lexi C said:

Hey Jacqui np.

Dana wow..that carzy to hear about Kaiser. Cause i was thinking of switch to them.

Cedar is no better. I guess like Jacqui said, i should be grateful that most all of exp are being cover right now

Dana hope it works. I kinda of dealing with same isuse for both mu bottom and FFS

 

 

 

 

@Jacqui sorry if this got hijacked:

 

@Lexi C So far I've had nothing but positive experiences with Kaiser with the exception it does take a little time to schedule things initially.  That said, Kaiser P plans are not all the same. Medicaid/care plans or federal employee or ACA plans don't cover as much as private or employer based plans.  And- California is a whole different beast because Medi-cal has legal stipulations that mandate trans coverage that other states don't.  That said- private or employer based plans in the rest of the country by Kaiser all adhere to the same rules as private California plans so they are great.  I get bottom surg, (I get to choose Johns Hopkins program or they will even fly me and put me up in a hotel to go to Oregon),  FFS, trachea shave, voice therapy, facial electrolysis , therapy, etc all covered except for normal co-pays which for me aren't much because I have a top tier plan. (finally getting my $$ worth since I pay almost $10k a year for myself being self employed) 

One thing about most carriers is they usually have a Case Manager person- you may have to ask to be assigned one, who helps you navigate all the hoops since there are so many moving parts to trans care.

Before you change insurance, always get on the phone with someone and ask about specific coverage criteria.  Most carriers have different levels or plans and coverage can vary considerably between those plans.