Topic: US Medicare choices and SRS

[Asche]

I'm planning to retire in two months, so I'll be switching from my company's health plan to some flavor of (USA) Medicare.  (I got part A when I turned 65, but not part B.)

I originally hoped to get my SRS while I was employed, so my company would pay for it, but that no longer seems realistic (long story.)

I'm debating between Original Medicare plus medigap and Medicare Advantage.

Does anyone know how Medicare and Medicare Advantage compare in terms of covering SRS?

I don't mind having a co-pay; for me, the big advantage of having insurance cover it is that insurance companies always gets a heavily discounted rate for everything; if I simply pay it all myself, I have to pay the ridiculously inflated rates that hospitals and providers charge the uninsured.

[AllieSF]

I have Medicare plus MediGap insurances.  Based on the plans I selected, for major surgeries, non-trans related, I pay nothing.  For Trans related I am not sure.  I had my BA and then my FFS done by doctors that said that they accepted Medicare AND Medicare approved payment for their services.  However, when I asked Medicare directly when I was post op they told me that my BA was not covered and only part of my FFS was.  I am still waiting to be told so by my surgeons, both at UCSF Medical in San Francisco.  Time will tell.  As I understand it, Medicare does pay for bottom surgery.  The problem with that is for me, the the nearest surgeon who accepts Medicare is in the Los Angeles area, making any revovery and follow up services that much more difficult and expensive!

As I understand it, the Medicare advantage is an HMO where one is limited to doctors in their plan.  Here in California I know many who have the Kaiser HMO plan (none are seniors yet).  Kaiser from what I can tell pays for most of the Trans surgeries, BA, FFS and Bottom, plus electrolysis for the genital area for the bottom surgery and I am not sure about the face.  Their Medicare coverage should be similar but needs to be verified.  Also, each Kaiser region is like being in a different State, because their coverage varies region by region.  So, check that out too.  Plus, not all can offer you these trans related services.  Ask how they would handle it for you to get those services in a different region.

So, the problem is that with both Medicare Original and Advantage, doctor selection may be very limited (Kaiser uses their own in house surgeons that I never heard about until friends used their services).  Kaiser is different because they offer full in house service (doctors, hospitals, nurses, therapists and pharmacy).  Other Advantage plans do use/accept different hospitals, surgeons and independent pharmacies. The advantage with an Advantage plan is that they may offer you a wider selection of surgeons.

These are my recollections of what I have read and heard.  So, please do follow up, calling Medicare (surprisingly fast response times to talk with someone), the providers of other Advantage plans and ask as many questions directly to them as possible.  By doing that you could become a knowledge center about Medicare for the rest of us!!  Please let us know what you find out.  There are a lot of seniors here that may want to know.

Good luck and thanks,

Allie

[Asche]

In my area, there are Medicare Advantage plans that are "preferred provider" plans -- you don't have to stick with the in-network providers.  That's probably what I would go with, rather than an HMO.

[Confused1]

I have been on Medicare with Medipak G Plan Blue Cross for most of the year. Had PET scan, Lupron, 39 radiation treatments and numerous doctor visits. So far I have paid 0$. I don't know if it will be the same with SRS, but they do cover it if you fit their requirements.

I first called the SRS doctors office I am considering and was told something that the Medicare people later told me was wrong about each state having different requirements and going across state lines. The doctors office person who handles SRS told me to call Medicare for specifics.

I made a call to Medicare to find out their requirements. The first person I talked to read of a list that sounded similar to WPATH requirements. I tried to get specifics since I am on Lupron and got transferred to a second person that basically did the same. Neither could even pronounce Dysphoria. Second person told me to have my provider call the provider line.

My therapist doesn't have any idea, but has given the name of a PHD level therapist in another city close by she thinks might know.

If anybody else gets it figured out please Post the answer so we all know!

Confused1

[Rayna]

I'm on Medicare Advantage through Anthem PPO. While you can go out of network, you will pay more plus I think it's a separate deductible. But the network is very broad here in Colorado. And their coverage out of the region is good. Check it out carefully before you sign up.

The HMOs like Kaiser generally are well liked (my Mom and sister are on it, and lots of trans people in California have gotten good care), but Kaiser is weak in my area and the other HMO in Colorado will only cover emergencies out of the state.

When I called Anthem about coverage on a different topic, they told me the Medicare coverage rules apply.

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[Rayna]

Also related, for therapy Medicare will only cover lower-level LCSW therapists or PhD psychologists. Not the mid-level but common Licensed Professional Counselor LPC. So we are private pay on our therapy

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[Confused1]

Also related, for therapy Medicare will only cover lower-level LCSW therapists or PhD psychologists. Not the mid-level but common Licensed Professional Counselor LPC. So we are private pay on our therapy

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Thanks Randy,

I have to pay out of pocket for my Masters level therapist. She gives me a very good discount since I am on basic Medicare. She told me pretty much the same thing.

Confused1

[Asche]

When I look at the descriptions of the Medicare Advantage PPOs, they look an awful lot like the plans my company was offering.  Are there any "gotchas", where the Medicare Advantage plan is missing stuff that would normally be in a company-provided group plan?

Also: I don't know about "Masters" counselors (is that the same as MSW?)  All the therapists I've dealt with are either PhDs or CSW's.   One that I had for a long time was a psychoanalyst, and she said that having an "R number" was key to getting insurance to cover it.  I think the issue is having a well-recognized certification, so that the insurer (who doesn't know squat about how good your particular therapist is) can trust that the "therapist" isn't just some random person who wants to collect insurance money.

[Rayna]

I've noticed no difference in going from my employer PPO to Medicare Advantage. Just tweaks in copays, deductibles etc.

A therapist will know if Medicare will pay them. State certifications vary. We have Licensed Clinical Social Worker LCSW, and Licensed Professional Counselor LPC which requires more training and hours of supervision to get licensed. Medicare pays our LCSW's but not LPC's for whatever reason. And they pay PhD's. I think MSW is a degree but not a certification here in Colorado.

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[Confused1]

Also: I don't know about "Masters" counselors (is that the same as MSW?)  All the therapists I've dealt with are either PhDs or CSW's.   One that I had for a long time was a psychoanalyst, and she said that having an "R number" was key to getting insurance to cover it.  I think the issue is having a well-recognized certification, so that the insurer (who doesn't know squat about how good your particular therapist is) can trust that the "therapist" isn't just some random person who wants to collect insurance money.

I think Randy is right. Seems certifications might vary by state. I just wrote here what she told me she is. With what she is charging me I can't go wrong.  She has written letters that were accepted for both HRT and surgery. That serves my purpose. My second letter will probably cost much more.

Confused1

[DebbieB]

By 2014, the coverage by medicare for SRS was very good.  After Trump in 2017, the coverage was spotty at best and many friends who had scheduled GCS in 2016 were being told that they had to put up the money up front, that they would be reimbursed after the surgery, and then didn't get the promised reimbursement.  Several states passed rules that required Medicare Advantage and Medicare Supplemental plans to provide the coverage on the same terms as other surgeries.  So the answer depends largely on the state where you live.