Medicare, HRT, and Roadblocks

[LauraE]

I recently turned 65 and, through my former employer, just subscribed to their Kaiser Senior Advantage Medicare Plan (with Part D). Last night, i noticed that Kaiser had finally posted my full plan information on my online account. Upon reading it, though, i discovered that Kaiser would not be providing any transgender services as part of my plan. This was quite disconcerting and made it difficult to sleep that night. I'd read so much about Kaiser's transgender services that this really set me back on my feet.

Today, i reviewed my Kaiser plan again, as well the research about Kaiser's services. Then, i called Kaiser for clarification. While i spent more than an hour on the phone with them, she (the representative) and i were very patient with each other. Although it was clear that Gender Correction Surgery would not be provided under my plan, my primary question was whether hormone therapy would be covered, including doctor visits, lab tests, and hormones. She spent quite a bit of time reading Kaisers' literature and at one point, asked me for the names of drugs that might be prescribed, so she could check whether they were covered by my prescription plan. Fortunately, Susan's Place has a wealth of information about hormone treatment, including a nice wiki article about each and every drug that might be used by transwomen. I provided these to my contact.

She wasn't aware that Kaiser had their own transgender department, so i both informed her about it and provided her their phone number. She called them, while i was on hold, to talk to them about coverage and drugs. Her initial information was that hormone treatment would be covered, including doctor visits, labs, and some of the drugs i'd mentioned.

To access these services, i'll need to meet with my primary physician to ask for a referral to Kaiser's Multi-Specialty Transition Department (MTD) in Oakland. (I live about 80 minutes from Oakland, so this isn't a big deal.)

So, today there's good news and bad news. The good news is that hormone therapy will be covered, so at least i can get started on my journey. Because protocol requires that i be Full Time for at least a year before i can request surgery, i know that i'm at least two, perhaps three years from surgery, so the "bad news" component isn't problematic at this point in time.

Just another day in paradise.

Laura

[DawnOday]

I have Group Health here in WA. Soon to be Kaiser. I have nothing but praise for my care. I am also on Medicare. I went to the therapist and after 3 meetings I had my letter, I went to the doctor who prescribes the Hormones and after my first visit I received my hormones on the second. I have now been on them for a month. I have also been offered speech therapy which in actuality is transitioning coaching. Not only speech but mannerisms, walking in heels and if I want makeup application, that is available too. They will also pay for an orchi and if medically necessary a GRS but all the cosmetic stuff you are on your own.  I too am 65 next month and I don't look at it as I will have 3 years to wait. I've been living on borrowed time for 25 years, They only gave me five. Fooled em.

[Michelle_P]

Thanks for posting that info, Laura.  I'm on an individual plan with Kaiser Northern California right now, and it DOES cover GCS, and FFS if you can convince them of a medical need.  Heck, it will even cover electrolysis once I hit the 6 month point on anti-androgens. 

I didn't realize that the Medicare version did not cover anything past HRT.  That gives me a hard deadline in 2 years and 1 month.  Damn.

Hey, waitaminute...  One of our Kaiser support group members is on Medicare, and is lined up for part 2 of two-stage SRS in a few months.  She's definitely not paying for it out of pocket.  I wonder if they gave you a stale piece of information?

This is interesting:
http://www.transequality.org/know-your-rights/medicare

What Does Medicare Cover for Transgender People?

Medicare covers routine preventive care regardless of gender markers.
Medicare covers routine preventive care for all eligible persons, including mammograms, pelvic and prostate exams. Medicare and many private plans may initially refuse coverage of services that seem to not match the gender of the person in Social Security records. Medicare and insurers often have a computer-matching program that only allows services to be paid for if the gender "marker matches," as a means of preventing mistakes and fraud in billing. This has the unintended consequence of denying claims for procedures that many transgender people need. However, Medicare beneficiaries have a right to access services that are appropriate to their individual medical needs and necessary care should be provided regardless of the gender marker in one's Social Security or other records. Later in this document we discuss what to do when coverage is wrongly denied due to an apparent gender mis-match.

Medicare covers medically necessary hormone therapy.
Medicare also covers medically necessary hormone therapy for transgender people. These medications are part of Medicare Part D prescription drug plan formularies (lists of covered medications) and should be covered when prescribed. Sometimes coverage may be initially wrongly refused due to an apparent inconsistency of the hormones with a gender marker in a person's records. Nevertheless, Medicare beneficiaries have a right to access prescription drugs that are appropriate to their medical needs.

Medicare covers medically necessary sex reassignment surgery.
For many years, Medicare did not cover sex reassignment surgery for transgender people due to a decades-old policy that categorized such treatment as "experimental." That exclusion was eliminated in May 2014, and there is now no national exclusion for transition-related health care under Medicare. This means that coverage decisions for transition-related surgeries will be made individually on the basis of medical need and applicable standards of care, similar to other doctor or hospital services under Medicare.

What Happened to the Medicare Transgender Exclusion?

In 1989, Medicare adopted a National Coverage Determination categorically excluding what it called "Transsexual Surgery" from Medicare coverage, regardless of a person's individual medical conditions and needs. In May 2014, the U.S. Department of Health and Human Services (HHS) Departmental Appeals Board decided an appeal from a Medicare beneficiary and decided that the 1989 exclusion was based on outdated, incomplete, and biased science, and did not reflect contemporary medical science or standards of care. Accordingly, the Medicare policy of categorically excluding coverage of transition-related surgery, regardless of medical need, was invalidated. This means coverage decisions for transition-related care will now be made on an individual basis like all other services under Medicare.

You might have to work through MST Oakland and your therapist to get letters of medical necessity, but once that's done I bet they'll cover it.  It's certainly worth pushing on.  Without the letters they are likely calling it cosmetic, which isn't covered.

Push back on it.  See if you can start seeing a therapist on the Gender Therapist Team on this page:
https://thrive.kaiserpermanente.org/care-near-you/northern-california/eastbay/departments/transgender-care/
I drive about an hour to see one of these folks every 3-4 weeks, as well as monthly (soon biweekly!) group sessions.  They're on the inside track with MST, and often have office hours at other sites around Northern California.  As insiders, they know which buttons to push to get you approved by their internal weekly surgery screening meetings where they decide the "medically necessary" part on the magical "individual basis".

Gotta know which buttons to push and levers to pull... Hey, my military experience came in handy after all!

[LauraE]

I'm on an individual plan with Kaiser Northern California right now, and it DOES cover GCS, and FFS if you can convince them of a medical need.  Heck, it will even cover electrolysis once I hit the 6 month point on anti-androgens. 

While i do expect to push back, i'll probably work at a higher level than Kaiser. I'm aware of the order that forced Kaiser to provide services to the transgender community and they have provided those services to most of their plans. However, for plans like mine, which are not individual plans, but group plans provided by a former employer, they are allowed to discriminate. I'm not entirely thrilled about it.

Laura