Gender Reassignment Surgery For Medicare Members - Effective Date on Jan 1, 2016

[Sheila_the_voice_within]

check out
priorityhealth medical policy 91612 (pdf)

https://www.priorityhealth.com/provider/manual/auths/~/media/documents/medical-policies/91612.pdf

MEDICAL POLICY No. 91612-R0
GENDER REASSIGNMENT SURGERY FOR MEDICARE MEMBERS
Effective Date: January 1, 2016
Date Of Origin: August 12, 2015

I. POLICY/CRITERIA
Gender reassignment surgery, including pre- and post-surgical hormone
therapy, is considered medically necessary when ALL of the following criteria
are met:
1) age 18 or older, AND
2) has confirmed gender dysphoria, AND
3) is an active participant in a recognized gender identity treatment program,
AND
4) capacity to make a fully informed decision and to consent for treatment.
If medically necessary criteria for coverage for gender reassignment surgery are
met, the following conditions of coverage apply. ...

(pdf)

[crazycool86]

love it

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[TechGirl]

So if Medicare is covering GRS, wonder how long until Veterans Affairs and the military do as well.

[Deborah]

If Medicare covers it then I'm pretty sure that TRICARE for life has to cover it too.  I'm hoping the rest will follow as soon as they finish all their "studies" and make a positive decision on transsexuals in the Military this spring or summer.  Assuming the decision is positive they cannot then continue to deny medical care.


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[Sharon Anne McC]

*

It's one thing finally approaching coverage.

It's still a great leap finding any surgeon who will accept what MediCare pays.

I'd like to know what '3) is an active participant in a recognized gender identity treatment program' means.  Is this something as basic as treatment by your primary, internist, or endocrinologist, or is this akin to the Stanford or Janus 'programs' of the 1970s?

Will MediCare re-imburse for someone who travels overseas if they can't find an acceptable provider domestically?

I thought this coverage was settled three years go?  There was a thread here at Susan's about that announcement.

*

[Joi]

My understanding is that Medicare was forced to cover GCS due to a lawsuit in 2014.
Before deciding on a surgeon in Bangkok, I called the offices of some of the more well known surgeons in the US to see if they would accept Medicare.  Not one of them would.  I have a supplemental policy that would have covered all that Medicare didn't cover, but it didn't make a difference.  Perhaps there are a few "newer" and less experienced surgeons that are performing the surgery, but I don't know who they are.  I wanted a surgeon with a proven track record.  The most experienced are in Bangkok.

[kittenpower]

My understanding is that Medicare was forced to cover GCS due to a lawsuit in 2014.
Before deciding on a surgeon in Bangkok, I called the offices of some of the more well known surgeons in the US to see if they would accept Medicare.  Not one of them would.  I have a supplemental policy that would have covered all that Medicare didn't cover, but it didn't make a difference.  Perhaps there are a few "newer" and less experienced surgeons that are performing the surgery, but I don't know who they are.  I wanted a surgeon with a proven track record.  The most experienced are in Bangkok.

Maybe a surgeon would be more inclined to accept Medicare for cosmetic SRS rather than full SRS given the difference in cost; I realize it is not the ideal solution for many of us, but it may be acceptable for some, as you would have the appearance of a normal vagina, with sensation, and a functioning urethra.

[Joi]

I think that the crux of the matter may be (and I'll admit I'm no expert on Medicare) is that once a provider agrees to accept Medicare,  the surgeons would be forced to accept patients with or without supplemental policies.

I have read (on this Forum) a statement from girl that was going to have GCS surgery wherein she would pay for the surgeons expense out of pocket and the hospital expenses would be covered by Medicare.  If one had a supplemental policy they wouldn't have to pay the hospital amount that Medicare doesn't cover.  If you didn't you would have to pay for the hospital charges that Medicare refused to pay.

[traci_k]

While Medicare was forced to cover GCS back in 2014, I believe it wasn't a blanket policy. If anyone may recall, back in November last year Medicare put out a request for comments on whether or not Medicare should cover GCS. I remember because I posted the article and encouraged members to submit comments. Perhaps an overwhelming number of us submitted comments that were taken to heart by the government. Great news! Now if we can only find more physicians willing to do the surgery and accept assignment of Medicare benefits for payment.

[Shana-chan]

I also would like clarification on #3 but I also wish to know if having autism would keep on from meeting #4. Lastly, if they now cover (and to be honest, I'm very skeptical as this was said before they cover but they didn't...) SRS then, does that mean they cover hormones and the rest like laser/electro for hair removal etc.?

edit: Can't believe I forgot this but, does this mean Medicaid also covers any/all of this?

[Michelle86]

So if Medicare is covering GRS, wonder how long until Veterans Affairs and the military do as well.

I think that active military is not on board with gender changing, yet.

[Deborah]

Neither active nor retired are on board as we are all under the same medical system.  I expect this is one of the issues DoD is studying and will announce their decision sometime this spring.


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