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GRS and Insurance

Started by Ms Bev, October 31, 2011, 11:07:18 PM

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KristinaM

BCBSNC is covering surgery this year.  Most of their plans anyways, from what I hear.  I know that the State Employee's Health Plan (which is with BCBSNC) is covering it.  I'm scheduled for this summer!
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EmmaLoo

This might be helpful for billing codes and general GCS coverage information. It's the link to the Aetna BCBS insurance guidelines for Sex Reassignment Surgery. Your company would still need to add this coverage specifically to the policy for coverage if you have Anthem BCBS so you would need to check on those details.

https://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051166.htm

It's current and valid for 2017. At least in Indiana. Verified it myself.  ;D

Emma
Seriously, I'm just winging it like everyone else. Sometimes it works, other times -- not so much. HRT 2003 - FFS|Orch 2005 - GCS 2017 - No Regrets EVER!
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Brooke

I'm a bit confused on how the 55970 and 55980 are applicable to individuals who are transgender but not intersex. Are insurance companies treating them as the same diagnosis?


~Brooke~
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TaraJo

Yes, absolutely, insurance will cover SRS.  A lot of BCBS plans will cover it, but since each state (and sometimes individual cities) has their own BCBS, it varies depending on your plan.

For the past year, I've been working for BCBS for TX, IL, OK, MT and NM doing preauthorizations.  I've learned a lot about insurance, how it works and how it applies to us as trans people and I'm using that knowledge to get surgery taken care of this coming summer.  Honestly, I've been tempted to do a bit of an AMA  on it.

As far as the CPT codes, they aren't that big a deal.  In all honesty, the specific CPT codes aren't generally that important.  I mean, if you have a doctor who has you set up insurance yourself, absolutely, you want to find out what codes they use.  But when you look at the CPT codes, some of them are so similar to the next that it's really hard to tell the difference (on occassion, we actually have to change CPT codes when setting up preauthorizations). 

If you do have to set up the insurance yourself and you REALLY want to surprise the person on the other end of the line, I can tell you exactly the information they're going to need for a preauthorization.  First, best thing you can do is make sure all the providers are in network; if you have a PPO policy and a provider is out of network, call them up and ask about a waiver and you might be able to get them in network.... eventually.  Besides the CPT codes (which are codes for the specific procedures or treatments), you're going to need diagnosis codes (or DX codes, which in our case would probably be gender dysphoria) and lastly you would need NPI numbers for both the doctor and the hospital where they're operating (NPI number is just a simple identification number for healthcare providers).  The preauthorization will probably pend and you'll probably have to do a predetermination and to get that approved, they'll need clinical documentation that this procedure is medically necessary; for us that means the therapist letters.  Generally you have to fax those in. 

Sorry if it sounds a little complicated.  I spend 8 hours a day doing this (sometimes longer).  It's not complicated for me because of experience.  But if anyone is having issues with insurance or has any questions, I'd be happy to help.
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ReubyLouise

I have several questions.

1)  I have HealthNet Medi-Cal by River City Medical Group. I have this because of my income through IHSS in Sacramento County California. I believe I am eligible for another insurance through SEIU Local 2015, but I don't remember.  Does anyone know or if SRS or whatever it is called now is covered or how I can find out?

2)  I am 64, and thanks to my first wife, I have genital herpes. Will I be eligible for the surgery with it?

3)  I know I had another question, but all the yelling and fighting is distracting me.  So let me ask, what is FFS and BA?

4)  I am legally male right now, but I have the papers to change that on my birth certificate and ID. Can I still qualify for the surgery and have the insurance pay for it if I do that?

With love, ReubyLouise
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steph2.0

Quote from: ReubyLouise on February 15, 2019, 09:28:16 AM
I have several questions.

1)  I have HealthNet Medi-Cal by River City Medical Group. I have this because of my income through IHSS in Sacramento County California. I believe I am eligible for another insurance through SEIU Local 2015, but I don't remember.  Does anyone know or if SRS or whatever it is called now is covered or how I can find out?

2)  I am 64, and thanks to my first wife, I have genital herpes. Will I be eligible for the surgery with it?

3)  I know I had another question, but all the yelling and fighting is distracting me.  So let me ask, what is FFS and BA?

4)  I am legally male right now, but I have the papers to change that on my birth certificate and ID. Can I still qualify for the surgery and have the insurance pay for it if I do that?

With love, ReubyLouise

I can help with #3:

FFS = Facial Feminization Surgery
BA = Breast Enhancement

Stephanie


Assigned male at birth 1958 * Began envying sister 1963 * Knew unquestioningly that I was female 1968 * Acted the male part for 50 years * Meltdown and first therapist session May 2017 * Began HRT 6/21/17 * Out to the world 10/13/17 * Name Change 12/7/2017 (Girl Harbor Day) * FFS With FacialTeam 12/4/2018 * Facelift and Lipo Body Sculpting at Ocean Clinic 6/13-14/2019 * GCS with Marci Bowers 9/25/2019
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TaraJo

Quote from: ReubyLouise on February 15, 2019, 09:28:16 AM
I have several questions.

1)  I have HealthNet Medi-Cal by River City Medical Group. I have this because of my income through IHSS in Sacramento County California. I believe I am eligible for another insurance through SEIU Local 2015, but I don't remember.  Does anyone know or if SRS or whatever it is called now is covered or how I can find out?

2)  I am 64, and thanks to my first wife, I have genital herpes. Will I be eligible for the surgery with it?

3)  I know I had another question, but all the yelling and fighting is distracting me.  So let me ask, what is FFS and BA?

4)  I am legally male right now, but I have the papers to change that on my birth certificate and ID. Can I still qualify for the surgery and have the insurance pay for it if I do that?

With love, ReubyLouise

Not 100% certain on all of this, but best guess? 

1)  State laws have a big impact on what kind of coverage various insurance plans will offer.  California is a pretty liberal, trans friendly state so, yeah, I'd be surprised if they didn't cover surgery.  If you'd like, I could try to do a little research on your company website and see what I can find out.

2)  I believe Herpes is mostly a skin condition, so it would be easy enough to avoid by simply using a skin graft from another part of your body.  Admittedly, this has all the fun involved with a skin graft.  And it would depend somewhat on where the herpes are; if it's on the head of the penis, well, that's the part that is used as the clitoris so there's no skin graft that can be used for that.

3)  Facial feminization surgery and breast augmentation

4)  Again, I'd be amazed if your insurance can't find a way to get around that. 
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Linde

I am running into the problem to find a surgeon/facility who/that accepts my insurance.  I have a Humana Medicare Advantage plan, which is a PPO.  It seems that most SRS surgeons don't accept this insurance plan.  I know that the plan would cover the surgery etc. as long as I find an entity who will accept the plan!
I know of some other people on Susan's who have he same plan, and are also struggling to find a surgeon.
If anybody here knows of an SRS surgeon accepting a PPO plan, please let me know.
02/22/2019 bi-lateral orchiectomy






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Linde

I have now a very cooperative person in the transgender department of my Humana insurance.  But the only list for transgender surgeons they have to go by is the WPATH listing, and that is helplessly outdated.  That listing still has the University of Miami surgeon who was sacked for ethics violations.
Anyway, my insurance person will look up any doc who I ask her to lock up for possible coverage.
Do you folks know of any current listing of surgeons who do gender reassignment surgery?
Or can you let me know who did your surgery, and we could start to compile a list here on Susan's?
02/22/2019 bi-lateral orchiectomy






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steph2.0

I can't help you with Humana specifically, but when I get home I can supply a list of surgeons I considered who are in-network with Florida Blue. It might be a starting point.


- Stephanie


Assigned male at birth 1958 * Began envying sister 1963 * Knew unquestioningly that I was female 1968 * Acted the male part for 50 years * Meltdown and first therapist session May 2017 * Began HRT 6/21/17 * Out to the world 10/13/17 * Name Change 12/7/2017 (Girl Harbor Day) * FFS With FacialTeam 12/4/2018 * Facelift and Lipo Body Sculpting at Ocean Clinic 6/13-14/2019 * GCS with Marci Bowers 9/25/2019
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Linde

Quote from: steph2.0 on May 24, 2019, 04:43:30 PM
I can't help you with Humana specifically, but when I get home I can supply a list of surgeons I considered who are in-network with Florida Blue. It might be a starting point.


- Stephanie
That would help.  So far the only surgeons I was able to locate was Dr Kim of the University of Minnesota, and the Team of the Mayo Clinic in Minnesota.  I bet that there are some on the way between Fort Myers and Minneapolis!
02/22/2019 bi-lateral orchiectomy






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steph2.0

Quote from: Linde on May 24, 2019, 06:03:41 PM
That would help.  So far the only surgeons I was able to locate was Dr Kim of the University of Minnesota, and the Team of the Mayo Clinic in Minnesota.  I bet that there are some on the way between Fort Myers and Minneapolis!

Here is the list of doctors I'd compiled who were in-network with my insurance:

Rachel Bluebond-Langner, New York

Jess Ting, Mt Sinai Hospital, New York

Sidhbh ("Seev") Gallagher, Eskenazi Health Center, Indianapolis, IN

William Kuzon, Ann Arbor, MI

Loren Schechter, Chicago, IL

Robert Oates, Boston, MA

Kathy Rumer, Ardmore, PA

I know nothing about Oates and Kuzon. I don't have any direct experience with Dr. Rumer but have been cautioned about her. Nothing specific, so you'd want to do your own research.

I had in-person consultations with Dr. Ting's staff and they were great, but I'd gone there thinking he was an expert in the peritoneal method I'd read about, and it wasn't what I'd thought. Considering the cost of having it done in New York City and the long wait, I looked around some more. I had some interaction with Dr. Gallagher's team in Indianapolis, and had decided to go with her until I ended up with Dr. Bowers instead. @Denise was happy with Dr. Schechter, and we'll actually be visiting with him in August for a consultation for Cassie.

I hope that helps!


- Stephanie


Assigned male at birth 1958 * Began envying sister 1963 * Knew unquestioningly that I was female 1968 * Acted the male part for 50 years * Meltdown and first therapist session May 2017 * Began HRT 6/21/17 * Out to the world 10/13/17 * Name Change 12/7/2017 (Girl Harbor Day) * FFS With FacialTeam 12/4/2018 * Facelift and Lipo Body Sculpting at Ocean Clinic 6/13-14/2019 * GCS with Marci Bowers 9/25/2019
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Linde

Quote from: steph2.0 on May 25, 2019, 11:42:49 AM
Here is the list of doctors I'd compiled who were in-network with my insurance:

Rachel Bluebond-Langner, New York

Jess Ting, Mt Sinai Hospital, New York

Sidhbh ("Seev") Gallagher, Eskenazi Health Center, Indianapolis, IN

William Kuzon, Ann Arbor, MI

Loren Schechter, Chicago, IL

Robert Oates, Boston, MA

Kathy Rumer, Ardmore, PA

I know nothing about Oates and Kuzon. I don't have any direct experience with Dr. Rumer but have been cautioned about her. Nothing specific, so you'd want to do your own research.

I had in-person consultations with Dr. Ting's staff and they were great, but I'd gone there thinking he was an expert in the peritoneal method I'd read about, and it wasn't what I'd thought. Considering the cost of having it done in New York City and the long wait, I looked around some more. I had some interaction with Dr. Gallagher's team in Indianapolis, and had decided to go with her until I ended up with Dr. Bowers instead. @Denise was happy with Dr. Schechter, and we'll actually be visiting with him in August for a consultation for Cassie.

I hope that helps!


- Stephanie
Thanks Stephanie!  I will give that list to my insurance, and they can tell me if they are in network for me!
02/22/2019 bi-lateral orchiectomy






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