GRS and Insurance

[Dee]

Another question regarding insurance. I live in Massachusetts and surprisingly for a state that made it law that insurance companies have to cover trans related care, there are no surgeons here. If there isnt a surgeon in my network do I still get charged out of network rates?

If you're referring to private insurance policies (ie, not MassHealth), then yes, I believe doctors outside of MA are considered in-network. At least, this was true a couple years ago- someone I knew (also from MA) was covered through insurance, and went to McGinn. So I guess that kinda muddles it, since she now doesn't accept payment through insurance. Unless if I misunderstood this person.

I actually sent an email to her staff about a week ago, as well, and received the same response...

[Beth Andrea]

Another question regarding insurance. I live in Massachusetts and surprisingly for a state that made it law that insurance companies have to cover trans related care, there are no surgeons here. If there isnt a surgeon in my network do I still get charged out of network rates?

I would think it depends on your policy...for me, if there are no qualified Dr's "in network" for your needs then the out-of-network docs get the in-network rate.

Often insurances will have an "800" number for info etc. Maybe call and see what they say?

[BrenB]

I'm a Federal Employee, and they lifted the required exclusion for GRS beginning 2015. They didn't, however, require providers for Federal Employee Health Benefits to cover it. I currently have Blue Cross Blue Shield but will switch to Aetna, since Aetna is the only choice of plans in my region that will now cover GRS (for us Feds). I am now in the process of getting things set up to have surgery this coming year. Yay!!  It's open season right now for us Federal employees, where we chose the health plan we want for the coming year, so it wont take affect till January. But I want to go ahead and choose a surgeon, get the letters sent, and a consultation set up now. There is a long wait list for some of the surgeons.
I have discovered that even tho I am now (or will be Jan. 1) covered, most surgeons require their fee up front, and you get reimbursed by insurance afterwards. Since I am unable to do that I have to find one that accepts and is in network with my insurance. I have found two so far.
It is such a wonderful feeling, knowing this is available for me!

[Eva]

OK while it is a ways off, Id like to do GCS in the fall 2015...

My current "provider" (freaking rip off United Healthcare/Golden Rule) is leaving my state, SD... I have to decide between BCBS, Avera, Dakotacare, or Sanford Health plan...

Im just looking to buy private insurance like I have now because my income will be too high to get "Obamacare" tax break... I just get SCREWED as usual...

I have a "diagnosis" of GD and they are currently paying for a good portion of my doc visits, lab testing, HRT, psych visits, ect...

First I cant figure out whether I tell them Im male or female.... Im female with SSA, but pre op so not 100% on my documents....

Next Id think with buying my own policy Id get to decide if GCS is covered.... I figure if Im gonna get raped paying them they can pay for my surgeries when the time comes.... That includes trying to get my planned FFS with Dr Z covered just because.... Im fortunate to be able to pay out of pocket and take whatever I can get for reimbursement.... My first choice for GCS would be Brassard, not only "out of network" but out of the country, could be a problem???... Im not sure I can wait wait the LONG waiting times Bowers and the like have for surgery though... I still donno how long Brassards waiting list is anyway... For all I know its too long for me as well....

So I guess the question is how do I find out what transition expenses my new policy covers before buying???

All I can think of is just call them and ask them

Any advice would be appreciated because I dont have much longer to make up my mind on a policy....

[michelle666]

I just picked out my plan for 2015, went over the docs for anything that could be considered an exclusion and there was nothing that specifically excluded anything related to being trans! As soon as I get my card in the mail and the plan is in effect, I'm contacting Dr Bowers to have her people start working on getting my surgery covered!

[Eva]

Well from what I gather in my state anyway you cant buy an individual policy that doesnt exclude it... BUT who knows, I got nowhere calling them and asking them and that really sucked

They also do have a page online that pretty much says the WPATH requirements are all thats required

http://www.wellmark.com/Provider/MedpoliciesAndAuthorizations/MedicalPolicies/policies/Gender_Reassignment.aspx#__utma=149406063.1878386947.1416934638.1416934638.1416934638.1&__utmb=149406063.1.10.1416934638&__utmc=149406063&__utmx=-&__utmz=149406063.1416934638.1.1.utmcsr=google|utmccn=%28organic%29|utmcmd=organic|utmctr=%28not%20provided%29&__utmv=-&__utmk=32890558

So since I need insurance anyway I went with Wellmark BCBS, I guess I'll find out soon how their gonna treat me... Id think my psych and HRT and doctor and lab tests will be covered anyway... They are now but Golden Rule is pulling out of my state so I gotta get new insurance...

Since Im pre op I got to give them my female name and had to check "male" on the application fearing they might cancel it or use it in the future to deny a claim 

[michelle666]

I just did a search on my new provider and found this doc;
https://www.harvardpilgrim.org/pls/portal/docs/PAGE/PROVIDERS/MEDMGMT/MEDICAL_REVIEW_CRITERIA/FULLY_INSURED_TRANSGENDER_CRITERIA_0714.PDF
It appears they cover FFS. I never thought of having that because of cost but now I'm considering it.

[lavistaa]

Another question regarding insurance. I live in Massachusetts and surprisingly for a state that made it law that insurance companies have to cover trans related care, there are no surgeons here. If there isnt a surgeon in my network do I still get charged out of network rates?

I've not found a good listing of what a plan covers- it's not on my portal, my GP wasn't sure (she's trans herself) and so on.  What am I missing? How can we find out?

[Amy1988]

The company I work for just switched to United Healtcare, does anyone know if the cover SRS?

[Reagan]

My insurance added GRS this year. The only problem is that there is a 50k lifetime cap on it. After consulting with two surgeons it appears that they offer two different pricings. One is a cash option of around 20k to 25k the other if you use insurance. It seems that hospitals will charge over triple the amount of a cash negotiated price if you use your insurance. So in my circumstance I am still better off paying out of pocket. Can someone explain this to me. I'm looking at Meltzer and he charges 23k as a cash negotiated price, but if I use my insurance it will cost upwards of 70k. His fee is the same no matter what. It's the hospital that added the extra cost. So it will end up costing me after deductible almost 30k out of pocket. >-bleeped-<ing hospitals!!!  I still don't understand how they can charge so much to the insurance company and get away with it. It's criminal!

[Wynternight]

My insurance added GRS this year. The only problem is that there is a 50k lifetime cap on it. After consulting with two surgeons it appears that they offer two different pricings. One is a cash option of around 20k to 25k the other if you use insurance. It seems that hospitals will charge over triple the amount of a cash negotiated price if you use your insurance. So in my circumstance I am still better off paying out of pocket. Can someone explain this to me. I'm looking at Meltzer and he charges 23k as a cash negotiated price, but if I use my insurance it will cost upwards of 70k. His fee is the same no matter what. It's the hospital that added the extra cost. So it will end up costing me after deductible almost 30k out of pocket. >-bleeped-<ing hospitals!!!  I still don't understand how they can charge so much to the insurance company and get away with it. It's criminal!

Who is your insurance company? Please tell me it's not Aetna. I will scream loudly and at great length if it is.

[Reagan]

Who is your insurance company? Please tell me it's not Aetna. I will scream loudly and at great length if it is.

YES!!! How did you know!

[Wynternight]

YES!!! How did you know!

Because I changed to them since they added GRS this year...**facepalm**

[Jill F]

Craptastic.  I have Aetna PPO.   Guess it's time to get my legal ducks in a row.

[Reagan]

Because I changed to them since they added GRS this year...**facepalm**

Check your summary of benefits. You will need at least 70k in coverage.

[Brenda E]

Wow.  I was going to switch to Aetna too, purely for the sake of taking advantage of their GRS coverage.  But if it's merely a vehicle for hospitals to screw the system and generate some rather large profits, I'll not bother.  The devil is in the details, I guess, and I appreciate the insight into the screwed-up system we have in the US.

It'll be interesting to see how this continues to play out.  My guess is that nothing will change: if it's cheaper to the patient to pay out of pocket, then the insurance companies will never end up paying a dime to the hospitals for GRS.  Aetna isn't likely to complain since it will rarely pay these inflated fees to hospitals for niche surgery that relatively few people ever undergo.  Quite a clever strategy, and I wouldn't be surprised if the insurance companies are working behind the scenes to engineer this particular pricing issue.

[Reagan]

Wow.  I was going to switch to Aetna too, purely for the sake of taking advantage of their GRS coverage.  But if it's merely a vehicle for hospitals to screw the system and generate some rather large profits, I'll not bother.  The devil is in the details, I guess, and I appreciate the insight into the screwed-up system we have in the US.

It'll be interesting to see how this continues to play out.  My guess is that nothing will change: if it's cheaper to the patient to pay out of pocket, then the insurance companies will never end up paying a dime to the hospitals for GRS.  Aetna isn't likely to complain since it will rarely pay these inflated fees to hospitals for niche surgery that relatively few people ever undergo.  Quite a clever strategy, and I wouldn't be surprised if the insurance companies are working behind the scenes to engineer this particular pricing issue.

Always check with you insurance. You may have the option of paying out of pocket, then submitting it back to your insurance for reimbursement. You may not get it all back, but you will most likely get a huge chunk of it.

[Brenda E]

Ah, I see.  Pay out of pocket up front, then approach insurance company and say, "Just had GRS.  You cover it.  Here's the bill - I'll need a check for the 80% (or whatever) that you typically reimburse."

I'm fairly certain that the plan I was looking at required pre-authorization for GRS.  My knowledge of the ins and outs of insurance are fairly poor, so not sure how this'll factor into the equation.

Anyway, it's at least a 18 months away for me, so not an urgent problem.  But glad to have a heads up about how the game is played when it comes to GRS so I can do my research and formulate a strategy.

[Jaelithe]

I'm insured through CareFirst BlueChoice HSA Bronze, when asking them about GRS they said that I would need the procedure codes and diagnosis codes to determine whether or not I'm covered.  My doctor then informed me that I would need to speak to the surgeon I choose to get those.  Is there a better way to figure this garglemesh out, or should I start looking for surgeons who preform this work in my area?

[mooncab]

Another question regarding insurance. I live in Massachusetts and surprisingly for a state that made it law that insurance companies have to cover trans related care, there are no surgeons here. If there isnt a surgeon in my network do I still get charged out of network rates?

There are actually a few. Dr. Melissa Johnson in Springfield MA did my surgery and I was covered 100% under MassHealth. There's also Dr. Richard Bartlett, Dr. Paul Costas, and Dr. Simpone Topal, all in Massachusetts. There are probably others I am forgetting.