No clear paths

[Hikari]

While section 1557 of the affordable care act supposedly ensures health care to transgender people who are on medicaid (at least in states where medicaid is expanded) I am finding it very hard to understand what paths I have towards GRS. I am in a position where I am for all practical purposes stealth, but I am unclear on who to go to for moving forward.

With the informed consent model getting hormones was fairly easy. With Medicaid paying for my hormones is also pretty easy. Changing all of my ID was pretty easy, finding a job that didn't ask for my old names was also pretty easy.

I suppose what I need is a doctor that takes Illinois Medicaid, E-mails to dr loren schechter which have went unanswered, and aside from him, I have no clue who might be willing to take Medicaid for GRS or even an orchi.

[Brooke]

For GRS you'll need the RLE. For an orchie you'll need a letter of recommendation.

My best suggestion is don't worry about that yet.

Find local support groups if needed, and start building your team of professionals (if you haven't already).

Do you have a gender therapist your seeing and a endo or HRT doc that is supportive and knowledgeable to the trans community?

Bottom line with Medicaid or any insurance for that matter is you need to have a paper trail and documentation that your following the wpath guidelines and recommendations. This includes psych, endo/HRT doc, 1 year of hormones and 1 year of documented real life experience. This documentation may need to come from a health professional rather than just the date of name change.

I believe in most cases the prior authorization for srs is on a case by case basis. That is, no national guidelines for a doctor to check the requirements and have auth approved as is the case for more common surgeries.

I also believe to start that auth you'll need to have met all the wpath's recommendations and have it well documented.

This means you can't even start the process for surgery coverage until 1 year RLE. As you say your stealth But have your name changed I don't know if that counts.

As it is a case by case basis , once approved you'll most likely be given a list of providers or asked for a preferred provider to perform the surgery. Due to the rarity of the surgery your insurance company may not have any surgeons that are in your network or are contracted with your states Medicaid. If this is the case you'll go through the prior authorization for an out of network surgeon and/or a guaranteed one time procedure reimbursement for the surgery  this is negotiated in writing between your insurance carrier and your surgeon.

It is unlikely that you'll gain much ground in finding a surgeon that takes Medicaid by cold calling due to all the variables and the case by case approval. Most docs will want to skip the resource suck until you have everything in place with wpath and insurance auth.


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[Hikari]

well RLE isn't an issue, I have been full time for quite a few years, and I have the paper trail for at least 3 years of that.... I would probably need to contact my old doctors who wrote my letters for Social security, dept of state, and DMV. I don't imagine getting that material would be too hard.

In fact it has been long enough, to where my current PCP doesn't actually understand that I am trans exactly (or maybe she does it isn't completely clear), see it is likely I suffer from an intersex condition, and since my previous doctor had that in the records when she asked me if I needed a gyno and I explained I don't have a vagina,ovaries, etc she just said "ah, I see". She then filed my previous prescriptions as per usual, including my hormones.

And as far as local support groups, there isn't one within 2 hours drive at least. I am in a very isolated part of IL. Chicago would be about 4 hours away for me, and being on medicaid, it is way too expensive for me to travel there.

I don't imagine it would be all that hard for me to find someone who could write me letters, but what doctor would take medicaid for SRS? I mean I have all Wpath requirements aside from therapists letters (After all I am very well adjusted, I have no need of ongoing therapy).

[Brooke]

I don't imagine it would be all that hard for me to find someone who could write me letters, but what doctor would take medicaid for SRS? I mean I have all Wpath requirements aside from therapists letters (After all I am very well adjusted, I have no need of ongoing therapy).

At this point I would contact member services for your insurance (phone number should be on card). Try and get a list of prerequisites and documentation needed as well as to where/whom you (or provider) needs to send it.

It appears that there is an individual on this >-bleeped-< post https://www.>-bleeped-<.com/r/asktransgender/comments/3n8wxn/just_got_my_surgery_date_im_on_medicaid_in/ that got approval in Illinois for srs.

She explains "When you have Medicaid they assign you a liaison/counselor to walk you through the different hurdles you often face with insurance companies."

Sounds like a call to your insurance carrier is in order.

The surgeon performing the procedure is
Loren S. Schechter  http://www.uplasticsurgery.com/loren-s-schechter-m-d/

He has an insurance specialist on his team who can assist you with obtaining pre-cert/pre-determination.

Dr. Schechter is a member of WPATH and follows surgery guidelines in the Standards of Care. You will require medical evaluation by primary MD or MD providing hormones and a letter of recommendation from a psychologist or other mental health professional.

You may want to get a referral from your pcp or HRT doc for a consultation.

Sounds like you have all the wpath stuff available.

Hope this helps clear a path for you!

Good luck!
Hugs,
Brooke






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