Hello,
     I have a question for those who have had their SRS covered by their health care insurance. I have everything in order, I have both letters and have chosen a surgeon. I have contacted my health care insurance and they told me that I am 100% covered with a $2,500.00 deductable. I was quite happy about that. So I contacted my surgeon and was told that she does not work with insurance providers, so I would need to pay her up front and my insurance would cover the rest, hospital fees and so on. Does that mean I need to pay her upfront, then submit her bill to me to my health care insurance to be reimbursed? Or because she is not in the insurance providers system, PPO, whatever that means, they will not reimburse me?
I would kindly thank you for sharing your experiences on this subject.
~Lauren


What health insurance provider do you have that said they'll cover it? Is that in the US? I'm not sure how that works, but I would guess that you pay the surgeon up front, get the bill and send that to your insurance provider for reimbursement. If your insurance provider said they'll cover it, I'd get that in writing just in case they decide not to once they get the bill.

~Sarah

Sarah,
    I have Anthem and live in the US, surgeon, Dr.Mcginn. I pay full coverage out of pocket, $700 per month, since I am self employed. Here's the link to their site.http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051166.htm Notice the effective date on that document at the top. Getting it in writing is a must, but the person I talked to only asked if this was "medically necessary " which is stated on both letters. Believe me, I was ready for a fight, and I may still have to, but. I may have to pick a surgeon that accepts medical insurance.
thanks,
~Lauren

You should ask her for clarification, but I think what Dr. McGinn means is that you have to pay her fee in cash and that other fees ( hospital stay related ) could be submitted to your insurance. Whether your insurance Co. will pay you back for the cash payment ... I do not know ( although I doubt it).

Wow, an insurance co that covers SRS ... very cool !  I hope more start SOON!

$8K+ a year is not exactly cheep, for most of the people on this board that kind of spendy, I'm not that sure that all that many people could afford that. 

OMG $8K would get you SRS in Thailand.

Janet

And my guess is you're going to pay into it for a few years before filing a claim.  If not, if you've only been on it less than a year, and post a bill like that, you bet the adjusters and auditors would be all over it.

Yes, it is a bunch each month. It covers my family. I have maintained this coverage for over 10 years.

I am curious if anyone has had this experience of the doctor not being in the insurers system, the patient paying for the doctor out of pocket, then the patient being reimbursed by the insurance company.
~L

aetna covers it as well on a couple of there plans but they follow the standards of care prety closely

Our union insurance covers it as well, so does the insurance for the City of SF.  You can get an insurance policy to cover just about anything, the only question is how much the premium is going to be.  As we should have learned from the current health care debate, the insurance companies do this for the profit, not for the awesome feeling they get by doing good.

Quote from: LaurenD on October 01, 2009, 06:04:54 PM
Hello,
     I have a question for those who have had their SRS covered by their health care insurance. I have everything in order, I have both letters and have chosen a surgeon. I have contacted my health care insurance and they told me that I am 100% covered with a $2,500.00 deductable. I was quite happy about that. So I contacted my surgeon and was told that she does not work with insurance providers, so I would need to pay her up front and my insurance would cover the rest, hospital fees and so on. Does that mean I need to pay her upfront, then submit her bill to me to my health care insurance to be reimbursed? Or because she is not in the insurance providers system, PPO, whatever that means, they will not reimburse me?
I would kindly thank you for sharing your experiences on this subject.
~Lauren


I live in Canada so I don't really know how our insurance companies compare to those in the US. However I think your best approach is to contact your insurance provider and ask them what the procedure is to file a claim under these circumstances to ensure that the insurance company would honor such a claim.  In my case I paid all costs up front and received an itemized invoice for everything provided that was associated with the surgery, this included travel and lodging expences.  The insurance company deleted what they wouldn't cover, and reimbursed me 80% of the remaining costs.

-={LR}=-

You pay McGinn in cash then submit your bills to your insurance company.  Any hospitals or doctors who take your insurance can be paid directly from them, less the deductible.  Talk to your insurance company to make sure.

I don't know of any GRS surgeons who accept insurance.  They need to rethink that for the benefit of their patients.  How many people have $20K laying around?  To me, they are taking advantage of a serious need.  How many heart surgeons require a patient to pay cash on the barrel head before they perform open heart surgery?

Julie

Very good points, Julie!


Dawn

Thank you for your help. I was feeling this was the answer as I gather more information from Dr. Mcginn and health care insurance.
~L

Ahh god i love being a Canadian girl, SRS fully covered without singing up to insurance or worrying about repayment

I have Anthem Blue Cross/ Blue Shield, and they'll pay 100%, so long as the surgeon is in network, otherwise it is 80% paid. 

I don't know what surgeons are  in network, but I'll will find out!

Love  - Steph

Why would they start accepting insurance? It will add a bunch of costs to the surgery itself since some doctors have to hire additional staff members just to deal with insurance companies. Plus with some countries covering the cost, they have plenty of business coming in, enough that many of the best have long waiting lists.

IOW, there is ZERO incentive for them to accept insurance.

Julie Marie and Syne are both quite right I believe !   Unfortunately this is how it is likely to stay for some time to come.  I cannot remember who, but I think there is a doc in the US that accepts insurance coverage directly. 

There are more and more companies that are willing to cover this, the devil is in the details of course.   I wish it was more common as that would bring down the costs.  As companies ( and govermental bodies ) start to see the advantage of covering GRS, more of us will get some help.

I work in insurance and would not bet the farm on them covering SRS until you have it in writing from a claims manager. I do know of Group Health insurance plans that cover SRS only because the employer asked for it to be covered. It is an optional covered surgery that is left to the employer at an additional fee. Most large Fortune 500 companies will only add this rider to their group plan if they are have a positive relationship with the GLBT employee benefit group who would have demanded this coverage.

To the best of my knowledge, no non-group health plans cover SRS. I have heard these stories from time to time, but have no definitive proof. I have heard of supposed cases of people being covered on their individual plans once they raised a stink and got a lawyer involved. Again, I don't know of any specific companies who will cover it on an individual basis.

If anyone has had it covered, please let us all know along with what you had to do in order for the insurance company to pay up. Thanks!

ps. I hope we do get health care reform passed this year. It will eliminate our pre-existing conditions which work against us as trans people. Part of the problem is that our "condition" is still in the DSM ,and viewed as a psychological problem and not a medical one. Most insurance carriers see us as a bad risk since we need monthly meds, and fear us becoming a long term depression cases. Many won't even consider us, under current law, to be eligible for health coverage. This is why I want us out of the DSM, and the new legislation to eliminate pre-existing condition clauses.

I've heard from my insurance company that they approve it on a case by case basis. I'm waiting to hear back from them if I am approved. However regardless of if they do or dont pay for it, i'm still going to be screwed. I've chosen Dr. Bowers to do my surgery as her office works with insurance companies now (not mine) but unless they send her payment in full before the surgery I will have to pay most of her fee out of pocket (not going to happen since I doubt I will ever have it) and then get reimbursed minus what owed after I send the claim to insurance........