Insurance Coverage

[DarkWolf_7]

I have a lot of questions, I know.

Okay, so I think I misunderstood my insurance plan and I do not need to be on hormones for six months. I will probably be on T first but I am not sure if there is a specific amount of time I should if I am more concerned with obtaining a flat chest for my well-being rather than having perfect results.

My insurance specifies that it covers bilateral mastectomy which sounds to me that it covers double incision and not the key hole (though I may not qualify for that surgery anyway)? And also, I am new with insurance so I am not sure about how to find out how much is covered without finding a surgeon first? When I look at the costs of these things even with the people who had insurance to cover some of it, most of it was out of pocket which is something I am not sure I will be able to do for a long time.

Thanks to anyone who answers.

[Greeneyedrebel]

My first question is....which country are you in? If it's the US, that may make some things easier for us to help you sort out, but it may complicate the answers.

Many insurance companies in the US will cover the bilateral mastectomy....but ONLY with breast cancer diagnoses and consider any other reason to be purely cosmetic....so no coverage of that. If you are lucky to enough to have coverage with one of the companies that WILL cover (or partly cover) it for trans folks, grats!

In the end, you will likely need to contact the insurance carrier directly and ask specific questions. There may also be stipulations such as in network or out of network for the surgeon. And that opens up a whole other issue of finding a surgeon that will meet those rules AND will do the surgery AND get the level of results you are looking for.

[FTMax]

In the end, you will likely need to contact the insurance carrier directly and ask specific questions. There may also be stipulations such as in network or out of network for the surgeon. And that opens up a whole other issue of finding a surgeon that will meet those rules AND will do the surgery AND get the level of results you are looking for.

This. What and how much is covered will vary not only by carrier, but also by specific plans. You'll need to give the benefits number on your card a call and have the card in front of you to reference the specific plan you're on. That is the only way you will know for sure. Tell them the plan you have, what procedure you're having done, and let them tell you the requirements or stipulations for coverage.

[aleon515]

Yes, does not mean they cover top surgery. I believe that they will have a clause re: gender surgeries. If they DON'T you are going to be better off actually (not sure if this is the case here or not-- more insurances are covering). But I believe they may be talking about cancer surgery or surgery to prevent cancer. It's really a different surgery.

--Jay

[DarkWolf_7]

My first question is....which country are you in? If it's the US, that may make some things easier for us to help you sort out, but it may complicate the answers.

Many insurance companies in the US will cover the bilateral mastectomy....but ONLY with breast cancer diagnoses and consider any other reason to be purely cosmetic....so no coverage of that. If you are lucky to enough to have coverage with one of the companies that WILL cover (or partly cover) it for trans folks, grats!

In the end, you will likely need to contact the insurance carrier directly and ask specific questions. There may also be stipulations such as in network or out of network for the surgeon. And that opens up a whole other issue of finding a surgeon that will meet those rules AND will do the surgery AND get the level of results you are looking for.

I forgot to mention, yes I'm US. And (luckily) bilateral mastectomy was listed as one of the surgeries covered for the treatment of gender dysphoria. The only trouble is if my insurance changes several months from now (my state just requires some sort of coverage for gender conforming surgeries).

[jumpthenexttrain]

I'm in new York state, and apparently whatever law that the governor passed regarding having private insurance companies cover trans surgery, was awesome. I got insurance through work in September, and my friends encouraged me to at least try to see if insurance would cover my surgery. (At this point I didn't know about whatever new law). I scheduled a consult, and waited a month for my insurance company to get back to me after the consult. They asked for documents saying how long I've been on testosterone, how long I've been living as male, and a letter from a psychologist saying that I'm mentally sound or whatever. Got all that and sent it and they ended up approving my surgery, and all I have to pay is a $150 copay. I'm listed as male on my insurance and everything else and they still covered it as a bilateral breast reduction, but it was done as a double incision surgery with nipple graphs like most top surgeries.

So what I'm saying is, don't give up hope. I've wanted surgery for 8 years, but I gave up on it ever happening years ago. But by some whim I finally got a break and got it done. You will too

[mooncab]

What state do you live in?

[DarkWolf_7]

I live in MA but I found out there was some weird complicated thing basically saying that my insurance doesn't actually have to follow the state law though they are working on solving that and insurances possibly changing to something else that doesn't cover...well long story short, that some time from now I might be able to get this covered though I don't know how much. Sometimes I just wish I could just explain to them how the dysphoria makes me feel but that wouldn't change anything.

Sorry for my rambling.

[HeyTrace19]

And also, I am new with insurance so I am not sure about how to find out how much is covered without finding a surgeon first?

You might try setting up a consultation appointment with a few choice surgeons (they are often, but not always, free).  The office staff will be able to tell you what your cost out of pocket would be if you are using an insurance plan that they accept.  The surgical fees may differ depending on the surgeon, the technique, and the amount of tissue that needs removal (and thus the time spent under the knife). 

[mooncab]

Can I ask what insurance you have? I live in MA and got my surgery covered through MassHealth under the new state mandate that says public insurance companies have to cover trans-related care. You might want to look into applying for MassHealth -- you can qualify for it even if you have primary insurance. And if you fall into the low-income bracket, you can qualify with no premium or co-pays.

[DarkWolf_7]

Can I ask what insurance you have? I live in MA and got my surgery covered through MassHealth under the new state mandate that says public insurance companies have to cover trans-related care. You might want to look into applying for MassHealth -- you can qualify for it even if you have primary insurance. And if you fall into the low-income bracket, you can qualify with no premium or co-pays.

I didn't know I could qualify if I already had insurance, though technically I have three different possibilities of insurance (either my parents or school) so I don't know if that would still be an issue. One of them actually does some coverage but would end up costing more in the long hall so probably not worth it.

But I'll look into MassHealth.

[Greeneyedrebel]

There is an insurance loophole (on the company side), especially with anything you get through an employer. For example, I'm in Louisiana but the group policy is set up and run through Blue Cross/Blue Shield of a different state. So they get to play by the rules of the state the policy comes from, which is South Carolina.