What procedures/surgeries/treatments do Medicaid and Medicare cover?

[Blackwaters427]

So, my girlfriend and I are having a bit of a disagreement on whether or not I should transition. I say definitely, yet my gf says I shouldn't because of the massive cost. The good thing is that im on both Medicare and Medicaid because I'm disabled. They're already paying for my therapist visits, but what else does it cover? Also what's the best insurance to be on if I want to do this?

[Veronica J]

Which country r u in

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[HeatherR]

It depends entirely on the state in which you reside.  Here in Washington, nearly everything, provided you complete the necessary steps(letters, therapy, etc) and establish medical necessity,  is covered completely with zero out of pocket.

Perhaps you should move here

[Brooke]

I am also in the same boat.

Currently Medicare's blanket restriction for transitional related surgeries (gcs, ba, and ffs) has been lifted. For traditional Medicare (not advantage) Medicare does not have a national policy of coverage, rather reviews each case on a case by case basis. The good part of this is Medicare uses wpath standards of care for approval/denial.

Check out www.transmedicare.com for more details and their section on known surgeons that accept Medicare.

Also a few months ago legislation was passed so that no Medical provider could deny care based on gender identity.

This is important as for a long time (since ban was lifted in 2014) Medicare had the reputation of approving coverage but reimbursement for gcs was less than an orchid.

The result of this was that surgeons who did perform gcs, and accepted Medicare simply refused services for Medicare patients wanting GRS.

What that legislation means is if they now refuse based on reimbursement rates they are at risk for losing their Medicare contract. This is Very good news for us, as the incentive for the surgeon's billing department to fight for market rate reimbursement is in their court, and not on the patients.

So... Medicare covers 80% of services typically and if you have cost sharing set up through Medicaid (typically set up with low income/dual eligibility) Medicaid Should automatically pay for deductibles and Medicare part A,B, and D premiums. This cost sharing also means that Medicaid will pick up the 20% for services that they would not typically cover or for dictators they are not contracted with. (Typically true for durable medical equipment and part A coverage- Hospital- which is what gcs covers.) Medicaid would also cover the 20% for office visits for providers and specialists they are contracted with. (Any specialists or providers they are not is a crapshoot.- This is part B coverage, which gcs would not be under.

If your still following me, great!

Notes. Medicare advantage also had ban lifted by Medicare, and advantage plans are required to cover AT LEAST what traditional Medicare covers, and sometimes they offer more.

If you live in a trans friendly state like California where gcs is covered under Medicaid, definitely look to see who Medicaid is contracted with as well as Medicare advantage plans to see if they have coverage for better/different surgeons.

As it's wpath recommendations they follow start making a paper trail. Expect to have to prove your taking the suggested steps, and get in early with counselors and specialists who will advocate for you and get you those letters of medical necessity.

This can be very useful for other services like permanent hair removal (have to go the reimbursement route) and if you need voice training, or other surgeries (ffs and BA) that are typically considered cosmetic. (Wpath states these all can be medically necessary)

Expect approval and prior sighs to take forever.
Expect to get denied several times (kinda like getting on ssdi)
Keep appealing and send stuff in fully loaded.
Advocate for yourself both to your providers and directly with insurance.
DON'T GIVE UP!

The three D's of insurance
Defer
Deny
Delay

They will try to wear you down with hoop jumping, so don't fret about it or get frustrated, it's Not Personal.

-------------------
Me

I took a deep dive into Medicare and Medicaid coverage over past several years, and have been on the lookout for any updates as I am also planning to get coverage through insurance.  Non trans related mostly but have achieved coverage for super rare/expensive treatments. If you have questions or need advice send me a pm.

Good luck and lots of Hugs!
Brooke






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Admin edit: Fixed link  Devlyn

[Brooke]

Grrr. Sorry it's http://www.transmedicare.com not .con :-)


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[Brooke]

Also forgot to mention both Medicare and Medicaid will pay for trans related office visits and HRT therapy. As well as stuff like bloodwork/diagnostic testing


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[Blackwaters427]

It depends entirely on the state in which you reside.  Here in Washington, nearly everything, provided you complete the necessary steps(letters, therapy, etc) and establish medical necessity,  is covered completely with zero out of pocket.

Perhaps you should move here

I've considered moving back to WA! Unfortunately that'd make me waaaaaay too far away from my son and the rest of my family. I live in Missouri. Also I was born in Yakima, WA. Where are you from, if I may ask?

[Blackwaters427]

I am also in the same boat.

Currently Medicare's blanket restriction for transitional related surgeries (gcs, ba, and ffs) has been lifted. For traditional Medicare (not advantage) Medicare does not have a national policy of coverage, rather reviews each case on a case by case basis. The good part of this is Medicare uses wpath standards of care for approval/denial.

Check out www.transmedicare.com for more details and their section on known surgeons that accept Medicare.

Also a few months ago legislation was passed so that no Medical provider could deny care based on gender identity.

This is important as for a long time (since ban was lifted in 2014) Medicare had the reputation of approving coverage but reimbursement for gcs was less than an orchid.

The result of this was that surgeons who did perform gcs, and accepted Medicare simply refused services for Medicare patients wanting GRS.

What that legislation means is if they now refuse based on reimbursement rates they are at risk for losing their Medicare contract. This is Very good news for us, as the incentive for the surgeon's billing department to fight for market rate reimbursement is in their court, and not on the patients.

So... Medicare covers 80% of services typically and if you have cost sharing set up through Medicaid (typically set up with low income/dual eligibility) Medicaid Should automatically pay for deductibles and Medicare part A,B, and D premiums. This cost sharing also means that Medicaid will pick up the 20% for services that they would not typically cover or for dictators they are not contracted with. (Typically true for durable medical equipment and part A coverage- Hospital- which is what gcs covers.) Medicaid would also cover the 20% for office visits for providers and specialists they are contracted with. (Any specialists or providers they are not is a crapshoot.- This is part B coverage, which gcs would not be under.

If your still following me, great!

Notes. Medicare advantage also had ban lifted by Medicare, and advantage plans are required to cover AT LEAST what traditional Medicare covers, and sometimes they offer more.

If you live in a trans friendly state like California where gcs is covered under Medicaid, definitely look to see who Medicaid is contracted with as well as Medicare advantage plans to see if they have coverage for better/different surgeons.

As it's wpath recommendations they follow start making a paper trail. Expect to have to prove your taking the suggested steps, and get in early with counselors and specialists who will advocate for you and get you those letters of medical necessity.

This can be very useful for other services like permanent hair removal (have to go the reimbursement route) and if you need voice training, or other surgeries (ffs and BA) that are typically considered cosmetic. (Wpath states these all can be medically necessary)

Expect approval and prior sighs to take forever.
Expect to get denied several times (kinda like getting on ssdi)
Keep appealing and send stuff in fully loaded.
Advocate for yourself both to your providers and directly with insurance.
DON'T GIVE UP!

The three D's of insurance
Defer
Deny
Delay

They will try to wear you down with hoop jumping, so don't fret about it or get frustrated, it's Not Personal.

-------------------
Me

I took a deep dive into Medicare and Medicaid coverage over past several years, and have been on the lookout for any updates as I am also planning to get coverage through insurance.  Non trans related mostly but have achieved coverage for super rare/expensive treatments. If you have questions or need advice send me a pm.

Good luck and lots of Hugs!
Brooke






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Thank you very much! So I have Medicare part A and B, but not D. What's the D?

[Deborah]

Part D is prescription drug coverage.  You do have to purchase that separately from the rest.

[RobinG78]

Thank you, I learned more today about my insurance , then I ever knew before.....I have both Medicare and Medicaid and I'm covered by part D, at no additional payments. I think Medicaid pays that for me. (Part D) I pay a low copay on all my meds. I was able, the other day, to see that almost all trans meds will be covered.

[HeatherR]

I've considered moving back to WA! Unfortunately that'd make me waaaaaay too far away from my son and the rest of my family. I live in Missouri. Also I was born in Yakima, WA. Where are you from, if I may ask?

Right now I live in Longview, quite reluctantly I might add.  I moved here from San Diego to change things up a bit.  Once I'm finished (Transition and School) I'm likely going back to San Diego.

[Harley Quinn]

Right now I live in Longview, quite reluctantly I might add.  I moved here from San Diego to change things up a bit.  Once I'm finished (Transition and School) I'm likely going back to San Diego.

Ouch... Longview is not a pleasant area. You should try it out further north. 

[Brooke]

Thank you, I learned more today about my insurance , then I ever knew before.....I have both Medicare and Medicaid and I'm covered by part D, at no additional payments. I think Medicaid pays that for me. (Part D) I pay a low copay on all my meds. I was able, the other day, to see that almost all trans meds will be covered.

That setup sounds like you have the cost sharing plan, which is great news. Also means your dual eligible (eligible for both Medicare and Medicaid) and may be on the slmb (different cost sharing programs explained here http://www.medicareadvocacy.org/old-site/InfoByTopic/MedicareSavingsPrograms/MedicareSavingsProgsMain.htm )

The cost sharing means a lot less paperwork in the end as you don't have to get prior auth through Medicare And Medicaid. Also means even if your state does not have good transgender Medicaid coverage your still covered fully through Medicare (which contracts on a national level)

That co-pay is there due to a weird legality issue which states that Medicaid cannot help with covering co-pays.

[Dena]

I am new to medicare but I need to pay for three things. Part B to the government, Part D to a company for prescription coverages and supplemental to pick up much of the co pay. The supplemental policy should cover transitioning costs as it pays for anything that part B would cover. So much for free medical care when you go in medicare.

[Brooke]

Dena, when you say your new to Medicare, did you recently retire?

do you have any state/Medicaid coverage?

If you have very low income (under 2k/month) look into the Medicaid coverage for the cost sharing benefits. If you can/are dual eligible, you should be able to get premiums and deductibles covered as well as use Medicaid like a medigap policy to cover the difference.

And yeah, getting full cost effective coverage is so difficult. Even when you retire your responsible for deductibles, premiums, co pays, and the missing 20%



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[Dena]

When you reach the age of 65 you must apply for Medicare or your part B rates get higher each year. I am still working and don't intend on filing for Social security until I reach the limit at 70. As for Medicaid, I have always had private or work insurance and most of the time, two policies at once (one was catastrophic and dirt cheap). I suspect with my retirement savings and Social Security I would be way over the limit for Medicaid and I have never been disabled and unable to work.

[RobinG78]

That setup sounds like you have the cost sharing plan, which is great news. Also means your dual eligible (eligible for both Medicare and Medicaid) and may be on the slmb (different cost sharing programs explained here http://www.medicareadvocacy.org/old-site/InfoByTopic/MedicareSavingsPrograms/MedicareSavingsProgsMain.htm )

The cost sharing means a lot less paperwork in the end as you don't have to get prior auth through Medicare And Medicaid. Also means even if your state does not have good transgender Medicaid coverage your still covered fully through Medicare (which contracts on a national level)

That co-pay is there due to a weird legality issue which states that Medicaid cannot help with covering co-pays.

My medicaid is through the state, my medicare is through social security as i'm disabled psychically. missing part of a foot due to OJI. I was paying $100 a month for medicare, but now the state covers my premium. I think??

[Lady Sarah]

Does anyone have any good news regarding GCS being covered by Medicaid and Medicare in Texas? Everybody I contacted told me "No", except for one that told me I'd need to pay 90% of the surgeon's charge.

[Brooke]

My medicaid is through the state, my medicare is through social security as i'm disabled psychically. missing part of a foot due to OJI. I was paying $100 a month for medicare, but now the state covers my premium. I think??

Yes. That would be the cost sharing program in action.


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[Brooke]

Does anyone have any good news regarding GCS being covered by Medicaid and Medicare in Texas? Everybody I contacted told me "No", except for one that told me I'd need to pay 90% of the surgeon's charge.

Check out the transmedicare provider list. As Medicare is nationally contracted, rather than state contracted (Medicaid) you should be able to find a surgeon that is contracted with Medicare.

As previously mentioned surgeons can no longer turn away customers who are trans IF they have a Medicare contract.

If their billing department does not advocate/push for better reimbursement they will end up performing the surgery at a loss.

Good news for us, as for each Medicare surgery that is approved and reimbursed at market rates it sets precedent for Medicare rates, and encourages surgeons who are not currently contracted with Medicare whatsoever (dr Meltzer comes to mind- who "officially opted out of Medicare") to obtain a Medicare contract and/or set up one time agreements for procedure reimbursements.

The end result is that we Should see official policy and reimbursement rates for in and out of network physicians for Transgender procedures just like official  reimbursement rates are seen for more common surgeries and procedures. This should encourage more surgeons to work with Medicare once the legwork is done, and we will get more and more options.

In regards to Medicaid in Texas it really depends on the dual eligibility AND the cost sharing. If that's in place Medicaid should cover the 20% Medicare does not anywhere in the country as it's under part A insurance not part B. Hospital (part A) billing is much easier to get reimbursement with out of state.

My advice, look into surgeons on transmedicare and also worry only about the Medicare prior auth.

There is no clear documentation I can find for prior authorization path. If I was at the point of attempting prior auth I would first call Medicare and ask specifically how to submit prior authorization AS a patient for gender reassignment surgery as well as specific requirements.

Current state of affairs is listed here
https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=282

Basically says for the time being GRS coverage will be decided by a case by case basis.

Whether that prior auth can be done before deciding on a surgeon or not I do not know. (Most common procedures have prior auth performed by physician offices)

One other thing to note is the transgender exclusion legislature will take affect on Jan 1, 2017. This is when the fire will be lit under the billing department for proper reimbursement rates from Medicare.