Susan's Place Transgender Resources

I hope this is the right place to post this.  Is it true that Medicare will pay for SRS?  Do they pay for the entire amount or just a portion of it?  I know that they pay for HRT since that is how I can afford HRT, I live on a fixed income.  If anyone knows about the lifting of the ban on Medicare paying for SRS I would really appreciate the advice, suggestions. 

Angelgrl

No U.S. based surgeon is accepting Medicare at this time because of the low rate of reimbursement.  I have been fighting with them to get mine for a while now. Those who say Medicare has covered it had private arrangements for reimbursement that the internet stories do not mention. Sadly, I believe the approval announcement for Medicare approving surgeries was a mid election season vote strategy and nothing with certainty. I will keep others posted when Medicare actually does start to cover our surgeries. :)

Actually, I believe this woman just arranged GRS using Medicare : https://www.susans.org/forums/index.php?action=profile;u=30711;area=showposts;start=0

You might want to read through her posts and/or message her.

Jenna Marie there is one difference those who are getting covered are getting covered through medicare advantage or supplemental plans. Jessica is right that straight Medicare I believe still isn't excepted by itself. I have only heard of cases with the other plan on top occurring as of now in regards to Medicare. Hugs
Mariah

Mariah : Well, yes and no. Stephanie there says they DO accept Medicare, she just needed a supplemental plan to pay for the difference between Medicare reimbursement and the total price (but the surgeon doesn't care where that extra money is coming from - if someone has the money in their bank account that's fine too). So they accept Medicare, it just doesn't pay 100%. Which, depending on the person, might still be a lot better than 0%; I could come up with $5000 a heck of a lot more easily than $25,000, for example.

Right. I agree that is what Stephanie. True 5 thousand is much easier come up with than 25 thousand.
Mariah

Thank you sisters for your prompt reply to my question.  I do have a supplemental, however it is Medicaid and not really sure if they will cover anything related to this.  As with Medicare though you are saying that I would need the actual money for the surgery in the first place and then Medicare would reimburse me after I filed the claim or would I just file the claim first and then if Medicare approves the surgery they would pay their portion?  The other question I have is what doctor will accept Medicare?  From what I have researched on surgeons that perform SRS is that they do not accept insurance.  Thank you for your replies.

Angelgrl

Would like the title changed to reflect Medicaid instead of medicare then if your on medicaid. Hugs
Mariah

As of May of last year US Depart of HHS Department Appeals Board ruled that Medicare may no longer have a blanket denial for GCS. So this was not an election year ploy.

http://www.nytimes.com/2014/05/31/us/ban-on-medicare-coverage-of-sex-change-surgery-is-lifted.html?_r=0

Hospitals and physicians that accept Medicare agree to accept what Medicare pays as full payment aside from Deductibles or Co-Insurance (20% of Charges for physician). Supplemental covers this amount, NOT the difference between what the doctor usually charges for the procedure and what Medicare pays. Medicaid is an acceptable Supplemental but since Medicaid usually pays less than Medicare pays, there is generally no additional payment to the hospital or physician. This means though, the physician CANNOT charge the patient for the difference.

The first Medicare covered surgery was done for Denee Mallon, a 74 yo veteran, by Dr Loren Schecter in Chicago at Weiss Hospital in Chicago. Whether or not Dr Schecter still accepts Medicare, I do not know.

Quote from: traci_k on May 08, 2015, 10:52:39 AM
Whether or not Dr Schecter still accepts Medicare, I do not know.

No. I have the Email copy of the denial plus know two girls who traveled there and were refused as well. Everyone was told that bills (hospital, lab, anesthetist , etc. ) have to be covered. There was a private pay arrangement on top of Medicare for the example you cited. Simply, Medicare ALONE will not cover SRS. :)

Bumping this thread to see if there has been any more progress with medicare coverage. I am definitely interested in pursuing coverage over the next year. If anyone here has had any success (or failures for that matter) the information would be extremely valuable.

Thanks!

Any news?

all the places i found here in US-CA:

they all seem to NOT want to or wont because they wont get re-paid?

any one having luck getting Medicare to pay this?

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 goes into effect January 2017

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 orchie.

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.

The current status  for coverage is here
https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=282


Sent from my iPhone using Tapatalk