Does anybody have any experience with getting treatment covered through MassHealth (Medicaid)?

Specifically, what kinds of treatment are covered, how much does MassHealth pay for, and how difficult is it to get approved?

I tried contacting them directly but they only said they cover "medically necessary" treatment and wouldn't go into specifics. That probably includes HRT and GRS, but is there any chance something like breast augmentation could be covered?

I realize you posted this about two months ago, but I thought I would get back to you in case you were (or anyone else is) still looking for this information.

Yes, MassHealth does cover some transition services. They cover HRT (Fenway Health in Boston is a great place for this) and as of January 01, 2015 they also cover GRS. I believe most state-based or related insurances now cover GRS and that they are pushing for coverage for any other insurance agencies operating with Massachusetts residents.

They do not cover breast augmentation or facial feminization surgery.

Unfortunately, I am not certain how covering GRS works for them. I found this post by trying to find the answer to this, myself. To the best of my knowledge, there are no GRS surgeons in Massachusetts, so I would imagine that they have to cover out of network.

Good luck if you're still figuring things out!

I'm trying to find more information on this myself. I live in Mass too and have insurance through work but they're self-funded so massachusetts rules don't apply. I'm thinking of opting out of my employer's plan and buying coverage. I feel like I've seen some info on coverage for GRS being pretty standard things like needing letters, one year real life experience, etc. I'm also trying to find more info on how GRS is covered since I need to know that so I can decide on what plan is best to buy. If you find any info please keep me in the loop and I'll do the same.

Hi there,

In fact, MassHealth does pay for breast augmentation as well as mastectomy and other transition surgeries. It is also the case that MassHealth considers all requests for procedures related to transition on a case by case basis. That means if it is not specifically listed as covered, the procedure may be approved based on the specifics of the case in question. So, as it turns out, MassHealth coverage for transition services is wide and comprehensive. And specific denials of transition surgical therapies are usually grounded in whether a patient conforms to proper diagnoses, protocols, etc., rather than being based on a particular procedure. Massachusetts new transgender inclusion law was created on the basis of WPATH standards of care. 

I believe that Masshealth pays for GRS, breast augmentation, HRT, and facial feminization surgery.  I'm looking into it and will hopefully have more info soon.

so far my masshealth/commonweath care has covered all my doctors visits, blood work and hormones and I have seen paperwork that says they will cover GRS and breast aumentation.

Massachusetts is a fantastic place to live if your trans, especially if your close enough to go to the fenway center, its wonderful going somewhere where you feel like the doctors know what there doing and no one looks at you weird. Plus they will use UPS or USPS to delver your medication to your door if your in the area. A few days ago realized that my Estrodol and spiro where getting low, jumped on there website order a refill and two days later my FeM&M's Showed up.

The only real shortcoming is the lack of actual surgeons in the area, if we had GRS surgery availible in state it would be truly wonderful. (and if it was in boston would save me about 2-3K in travel expenses for GRS)

Serena

Quote from: Valwen on January 09, 2016, 07:00:34 AM
so far my masshealth/commonweath care has covered all my doctors visits, blood work and hormones and I have seen paperwork that says they will cover GRS and breast aumentation.

Massachusetts is a fantastic place to live if your trans, especially if your close enough to go to the fenway center, its wonderful going somewhere where you feel like the doctors know what there doing and no one looks at you weird. Plus they will use UPS or USPS to delver your medication to your door if your in the area. A few days ago realized that my Estrodol and spiro where getting low, jumped on there website order a refill and two days later my FeM&M's Showed up.

The only real shortcoming is the lack of actual surgeons in the area, if we had GRS surgery availible in state it would be truly wonderful. (and if it was in boston would save me about 2-3K in travel expenses for GRS)

Serena

Thank you for sharing everything.

If I could ask, does this mean that MassHealth is covering GRS for you out of state, Serena?

I am not sure but I am hoping to find out in the near future. Though I am afraid to find the answer to that question as this insurance is likely the only way I will ever be able to have GRS, and it seems like a waste to have gone through all I have just to kill myself anyways.

Serena

Quote from: Valwen on January 18, 2016, 11:11:51 AM
I am not sure but I am hoping to find out in the near future. Though I am afraid to find the answer to that question as this insurance is likely the only way I will ever be able to have GRS, and it seems like a waste to have gone through all I have just to kill myself anyways.

Serena

A pair of doctors are being trained at Mass. General to perform GRS, don't worry. There will definitely be an option at some point. Personally, however, I would rather not have surgeons that inexperienced operate on me, so I was hoping to see if it was somehow covered elsewhere.

From everything I have heard so far, it isn't, and we need to wait for those doctors to perform the surgery. I do wonder if a case could be made for some freedom in selecting a provider, however. Being forced to go to only one option seems very unfair and I'm sure some argument could be made.

Serena, I believe Boston is presently setting up to do GRS in the very near future. I was just at a support meeting on Saturday and that came up. You may want to check into it. I am just south of you in RI


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there are a couple of in state individuals that might end up being able to do it, there is a two person team in boston, a cosmetic surgeon and a urologist who where planning on starting to preform it but there plans originally had them starting back in mid 2013, that got pushed to some time in 2014 and as far as I can tell they never actually did anything.

there are also two individuals currently in training who have expressed interest in going into GRS surgery once there training is finished that both said that boston was a possible city they had considered but nothing was finalized. so in short its a maybe perhaps some day it might happen situation, far from a certain thing.

it would be nice but as sybil said, this is a very delicate very complicated procedure and a single mistake can destroy your quality of life. That said not a lot of people want to be patient #1 in such a situation. one wrong nick and you can kiss climax goodbye forever, a diffrent wrong nick and your urinary track is a mess, a really bad one that goes unoticed and your bowel leaks into your body and you die.

lots to worry about. Still i will take it over dental work any day.

Serena

There's sure to be an exception with that kind of uncertainty and flip flopping. The coverage is mandatory, i.e. health-necessary. I can't imagine they can justify delaying a procedure simply because "oh, well, you know, Massachusetts!"

I will look more into it when I get back home (I am currently abroad into February) and try to update anything I find here. I suspect it's completely reasonable to get it covered out-of-state, but that it will take much nagging.

Also, my memory is spotty at the best of times, so I'm terribly sorry if someone reads this months down the line and sees no update (assuming we still need one) from me!

The issue is often with the insurance companies themselves they like to try and deny any claims that they think they can get away with or that they see as strange or excessive. Any excuse like going out of state for a operation is used to deny it.

On the other hand due to the hassle of fighting the insurance companies many surgeons won't take insurance unless they believe they will pay up without them fighting it. I know several trans woman who ended up having to take out loans from banks and then fight the insurance company to get reimbursed and pay of the loan. That's great if they will give you the loan but many trans people like myself do not have the trust of the banks due to low pay or other issues and could never get a 30,000$ loan.

Serena

When I first started transitioning, I was on MassHealth. They covered everything I needed at the time. HRT, therapy, dr visits, needles and syringes, ect. Fenway Health was great with helping me get everything setup.

Wow...it's great to see so many girls on here that are from Massachusetts/Rhode Island. I'm on the south coast myself. Also, It's nice to see Fenway getting such great reviews. I had my first appointment there yesterday and after talking to my doctor for a bit he gave me the informed consent forms and set me up with a follow up in two weeks where we will go over the form and I will most likely finally start HRT.

I have insurance through the federal employee health benefit system and was relieved to see that they covered everything (hormones, GRS, BA, facial fem surgery) as long as you have medical providers whom can document that the procedures are to treat gender dysforia. From what I have researched Masshealth covers the same things.

Nice to meet you all. I'm Brie. 42 years old. Just decided to try living. I got tired of feeling like life was something simply to be endured. xo

This may help.

http://www.mass.gov/eohhs/docs/masshealth/guidelines/mg-genderreassignment.pdf

I just got this email from my therapist:

At this time your insurance (Masshealth NHP) won't cover facial surgery. I believe a breast augmentation can be covered easily, as are hormones (ideally, one would take hormones first to see what growth your body can produce on its own). Other surgeries are "technically" covered, but your insurance won't pay for an out of state surgeon, and BMC is still working with insurers so that any patient on any plan can get surgery covered - until then, they have a wait list but are not operating yet.

I'm happy to talk to you more about your options. I fear that other surgeons who take insurance will likely not be able to work with yours... Then again, you are an excellent advocate and if you wanted to see if you can get surgery covered outside of the state of Mass, I'd be happy to support you in that effort."

The general rule is, if there it's a in state surgical option insurance will not cover out of state surgery. Currently there is no in state GRS Option so insurance should cover it out of state but that could get difficult soon with doctor oates gearing up to start GRS in mass. Once that happens people who have previous plans with other surgeons will end up fighting to keep there appointment dates with those surgeons as the insurance will try and deny them even though there surgery was approved 6 months ago. It's a complicated mess. It's also not super enviable that we will soon had no choice of surgeon, but at least the local option will save a ton on travel time.

Serena

I should amend my previous comment. BC/BS of Massachusetts covers everything, including FFS. The federal version covers no procedures at all and in fact this is the very first year they cover HRT. I will have to do some serious research come open season because after ten months on hormones I may start to want to look at some possible surgical procedures in 2017.

Thank you all for this information I'm effectively homeless (not in reality thanks to my brother though) and live off of mass health/food stamps. I just joined this board not 30 minutes ago and it was this exact thread that google found and pointed me to. I'm not remotely ready to start transitioning but its in the possible future plans if I feel like its something I definitely have to do. Im at the research everything try non permanent things out and see its truly right for me stage.