Any Advice For TS's Dealing With Healthcare Organizations?

[flatlander_48]

Hi:

A fellow member of another forum posted the following message about her dealings with the Kaiser Permanente organization. I am posting the message here in the hope that casting the net a bit wider may be helpful in generating some suggestions...


I know its not likely to get any responses, but I have a situation and am not
sure what to do.

I just got a call from my endocrinologist saying she hasn't seen me in about two
years and set up an appointment. My problem is she is the one who refuses to
treat me as a Trans person. Hell. All of Kaiser Permanente refuses. But she is
leading the charge so to speak. I made the mistake of following her instructions
to get a letter from a shrink confirming I was a TS and that I was a candidate
for HRT. Found out that asking about that is tantamount to asking for surgery
which would get me booted out of my HMO 10 months before the open registration
for changing, He3 wrote a letter saying I wasn't a viable candidate. She has it
in my jacket and used it to refuse treatment even though the psychiatric
department says they have no record of that report any longer. Amy suggestions
would be welcome. Unfortunately I am not expecting a flood of responses as I
rarely do from any groups.

[Krististeph]

I really don't know what to suggest, other than looking specifically for a pro-TG doc. I would immediately get a second opinion, to start. I do not knwo much abotu kaiser, but they may be a conservatively guided company, and while i do not prefer either political party, the liberal tendency will probably work with you more. Again I do not know any of the political affiliatiotions for sure, but based on the recent Obama / catholic stuff, you want to make sure your insurance is NOT conservatively oriented. If it is, I'm not sure what options you have, but in light of the recent political fighting, you might try appealing to the white house- explain your situation, and ask if they could help guide you to a more accepting insurance group. I do not know if that will work, but it can't hurt to ask. Also ask about litigation. I'm not crazy about the idea in general, but i really hate seeing any political or religious views being forced on others, regardless of their left-ness or right-ness (hey, everyone is wrong except for me, of course. :-))

Not sure if this helps at all, but frre free to continue the discussion, either public or private.

I do feel you pian, but i know I can't understand the depth of the pain that you feel from this... I would be so angry...

And you are evidently a bicycle rider- another reason to support you! You take care of your health instead of dieting on burgers and fries for decades, heck, we are supporting the insurance companies- we are the ones in good health! Screw them for not letting you ask for something back. (many naughty words)

I raced for Suntour in my teens (Suntour+Raleigh). Never had any Campy components... How are they? Always been envious of them. Now i ride with mid-low lever shimano- they work really awesome, i have to admit.

[Stephanie-L]

Pretty much no insurance company is going to cover most of the treatments for trans stuff. I am lucky, at least mine covers the counselling, the endo, and possibly the hormones. The only insurance I have heard of that covers things like SRS is the one for city employees in San Francisco, though there are possibly others, they are rare. Also, if you get a supportive doc they can code your treatment as other things (which will probably be true, just a different way of looking at it) so that insurance will pay. The problem here is with Kaiser Permanente, or as we used to call them "Kill them Permanently", they generally either use brand new docs with no experience, or docs who have had issues and can't get a job elsewhere. I would not go to them for anything, and this is just another reason. BTW, the very nature of insurance is going to make almost any company conservative, they are going to avoid paying for anything that they can, and this is an easy one in their eyes. Good luck.............Stephanie

[Kaitlyn Michele]

If she is just looking for hormones, just find a friendly doctor. It's actually quite easy. If she is serious about getting them, just do it.

Forget insurance. If she is spending all this time waiting for HRT just to get insurance money, maybe you should also question if they are neccessary for her..

[Julia_in_Pa]

To date those that do have insurance that does cover SRS and related surgeries concerning transition have yet to have any US surgeon performing such accept such insurance as payment.

Concerning medical specialists, GP's, etc; If any of those listed use ICD coding related to transsexual or Gender Identification Disorder (GID) they are opening up the patient to the scrutiny and more than likely exclusion of payment by the insurance company for anything related to the patent's trans needs.

Answer? Finding sympathetic healthcare providers that are willing to intentionally mis-code in order to push the procedure or medication through the patient's insurance for payment.

This has been done for me by my doctor in Helena Montana. My insurance had a very difficult time understanding anything dealing with intersexuality.
Instead of continuing to bang my head against the wall my doctor simply removed the wall.

Sadly this is a game that the trans patient in this country must continue to play in order for them to receive proper medical treatment paid for by their insurance company.


Julia

[Badtranny]

A fellow member of another forum posted the following message about her dealings with the Kaiser Permanente organization..[/I]

Kaiser is one of the most progressive HMO's out there. It's offered as an option where I work and I may be switching to them next year because there is a real good chance that SRS will be covered. As it stands their list of covered meds includes the entire HRT cocktail and GID issues are not specifically excluded like they are in my CIGNA plan. The head of medicine at Kaiser is a TS woman who transitioned a few years ago and she is very serious about bringing Kaiser officially into the modern age regarding our issues.

If Kaiser is not being helpful it's only because of the biases of the people on the front line. Unfortunately, certain people in certain parts of the country are incapable of getting past their own sad prejudices.

[Kaitlyn Michele]

Kaiser is one of the most progressive HMO's out there. It's offered as an option where I work and I may be switching to them next year because there is a real good chance that SRS will be covered. As it stands their list of covered meds includes the entire HRT cocktail and GID issues are not specifically excluded like they are in my CIGNA plan. The head of medicine at Kaiser is a TS woman who transitioned a few years ago and she is very serious about bringing Kaiser officially into the modern age regarding our issues.

If Kaiser is not being helpful it's only because of the biases of the people on the front line. Unfortunately, certain people in certain parts of the country are incapable of getting past their own sad prejudices.

Wow! I didn't know that. I was summarily dismissed when i tried with my insurance, like most people i know...i just assumed...my bad

[ReneeT]

Kaiser is one of the most progressive HMO's out there. It's offered as an option where I work and I may be switching to them next year because there is a real good chance that SRS will be covered. As it stands their list of covered meds includes the entire HRT cocktail and GID issues are not specifically excluded like they are in my CIGNA plan. The head of medicine at Kaiser is a TS woman who transitioned a few years ago and she is very serious about bringing Kaiser officially into the modern age regarding our issues.

If Kaiser is not being helpful it's only because of the biases of the people on the front line. Unfortunately, certain people in certain parts of the country are incapable of getting past their own sad prejudices.


Everyone with health insurance should take the time to understand their plan and learn some basics. Maybe I will write a primer someday. First of all, no two plans are alike. Even if it says Cigna, wwho i work for, or United, or Aetna, every employer has their own variation. Second, you need to know if your employer is fully insured or self insured. In the former, the employer pays a premium and the health plan functions as a true insurer, assuming all the risk and paying all claims out of its own reserves. If your employer is under 1000 employees, this is likely the plan you have. In this case, the insurance companies standard benefit language applies, which likely excludes all trans-related issues.

If your employer is self-insured, it means they pay all claims out of their own pocket, and the "insurer" is only administering the plan - paying claims, managing the network, etc. In this type of plan, the employer specifies the coverage, not the insurer. If the employer wants to cover (and pay for) daily massages for everyone, they can. If they dont want to cover trans or lgb related expenses, they make the choice not to.

If your company is self insured and does not provide trrans benefits, you may have an opportunity to change that (refer to my "Getting Involved" post). In this day and age, corporate America is getting more tuned in to the fact that people are assets, and its what yoyu do, not what youlook like or who you sleep with that adds value to their enterprise. If I leave Cigna, which has no trans benefits to go to Aetna, which does, Cigna loses and their competitor gains

[Aprilrain]

My insurance pays a grand total of $4 of my HRT. I pay $24 instead of $28. 4x24 months = almost a hundred bucks. :straightface:
Does this person need to transition or what? After the first 6 months, assuming no other problems exist, you could get away with seeing your endo once a year if you wanted, though twice is probably a better monitoring scheme. Cut back on the Starbucks and takeout, Dont drive for a week, turn the heat down, fore go the surf and turf, eat tuna, or steal the money from your SO (just kidding). Seriously Does this person need to transition or what!

[LeannL]

Just to add what Renee said, if the employer is self-insuring, then the person on the end of the phone may not even be aware of the policy specifics.

While, it may not help this specific person, the good news is that more employers are starting to cover SRS related expenses. As I work for a major pharmaceutical company who is interested in its public perception including various employer ratings. It recently got a perfect score in an LGBT friendly rating that was changed to include covering SRS. When it added SRS, a few people complained but were rapidly shouted down by those who described the issues surrounding our community.

While it isn't the best economy, if the person could change jobs to an employer who does cover SRS and related expenses, the problem would go away.

Leann

[Stephanie-L]

I did not know that Kaiser had become so progressive, it must be fairly recent. In my experience with them, many family members had Kaiser, I trained in a Kaiser hospital, they were very tight with the money. I also did not know that other companies are becomming more open to coverage of trans care. It will be something to look for if/when I change jobs, thanks............Stephanie

[RachelOKC]

Kaiser is regarded as pretty TG friendly so I'm a bit surprised with the OP's repost about someone's difficulties. It's a bit difficult to evaluate the situation based on the details provided. As Misty said, there's always people on the front lines who may be biased. They may also just be ignorant of TG needs and procedures, especially if the practitioners have little or no experience with TG members. Cant say I have much advice other than for the person to escalate the issue and file a member grievance.

I've personally experienced frustration in working with Kaiser Mental Health in my own town. While most of their clinicians have a basic familiarity with TG issues, there was nobody here who specialized in such. I found I had to go to KMH Oakland (a PITA in itself) to find a therapist with expertise. She is quite overloaded with clients and I get to see her barely once a month. The situation isn't perfect but it's better than nothing. I've heard that Kaiser is working to improve it's TG care policies and procedures but I'm not keeping my hopes high.

That said, many services for TG patients are covered. I attend a clinical support group at Kaiser Oakland run by my therapist and it's very helpful. Most of the men and women in the group are on HRT covered by their Kaiser plans. I can't say I know first hand of anyone being denied although I've heard some docs are confused as to how to proceed. It seems there isn't much policy right now on who handles what, so some have hormones handled by a GP, others may have it done by an endocrinologist. There's talk of opening a bona fide TG clinic, but that's just talk for now. Oh...and if you're fortunate enough to get a job with certain companies or municipalities...then your SRS/GRS will be covered though Kaiser.

[EnglishRose]

As others have said, it does depend on the individual plan no matter what insurance company. My United pays for all my endo visits, after copay, and I get my HRT meds under stores' generics programs (which costs me $17 a month right now). Also, my diagnosis (for filing to the insurance provider) is literally "Adult Gender Identity Disorder".

[flatlander_48]

Thanks to all who responded! I will pass the messages to the person who originally posed the question.

[Shapeshiffter]

I am going through Kaiser in San Diego. When I first went to them they had no guidelines and did not know what to do with me. I had to teach them. I've been on hrt for 9 months now. Meds are 20 per month, but lab work is expensive. If your friend is in san Diego send me a Pm and i will send a list of friendly doctors.

Brighid

[Empress Lainie]

Flatlander: I joined Caremore 4 yrs after my transition. My dilemma is that medicare will not change my gender without irreversible surgery (orchie, breast implants,srs),
but my ID is female. After I talked to the rep and decided to join them, I then told her I was trans, and if they ever addressed me as male, I would leave; but that billing to medicare had to say male; but nowhere else.

I asked my Primary Care Physician for HRT, she looked up GID and gave me the RX for estradiol and spironolactone. I pay $3 per month for my 30 pills, nothing for my spiro. I also pay nothing for my insulin or test strips for diabetes either, which is the primary reason I left United Healthcare/AARP for them.

I see F on my blood work and everything else medically. I went into the hospital as female for my 2nd pacemaker, and the nurse asked if I had a hysterectomy when taking my medical history. Later I went in again and was in the women's section in a private room (one advantage of being TS - you get a private room!) The nurse even got me shaving cream and a razor to shave after my 2nd day, when I told her I didn't have electrolysis and still had to shave.