Moving Forward w/ Health Insurance Coverage for Phalloplasty

This is proving to be such an interesting (read: challenging) process in trying to get coverage with my current insurance (that will likely be changing in the coming months). I currently have CeltiCare which is through MassHealth/Medicaid. I spoke with Katrina, Dr. Crane’s nurse last month after paying $150 for them to verify my insurance. I already knew that my insurer covers 100% of the procedural codes, since I had checked. However the issue is with the rate, or amount of money that Medicaid typically reimburses providers, which is a minuscule amount. Last month Katrina told me that they would not take my current insurance because of this reason, and I didn’t really push the issue. I essentially felt defeated (not because of Katrina) because this process is so emotionally draining and I figured WELL, I guess I’m going to have to go with my Plan B. However, I am interested in pursuing this option further before I move on to using another insurance. I have a couple months to kill in the meantime and I feel like even if I’m mostly likely going to use the insurance I end up getting through my employer, that pushing this issue with Medicaid can only serve as a catalyst for awareness and change for many others that are currently or will be pursuing phallo (or any surgery that Mass has no providers for at this time).

I received a call from Katrina today. She confirmed that my hormone letter had arrived and that she would make sure it was passed on to their scheduling person. I had no idea that this kind of letter was even needed until the time of my consult when I had already provided them with my two letters for surgery and then I was asked to also get a letter stating that I’m on hormones, what my start date was, that I’ve been taking them as directed, blah blah blah. I also had them add in for good measure that they supported my decision to move forward with phalloplasty and that it was a medically necessary procedure. This wasn’t asked for but I figured it couldn’t hurt.

I called CeltiCare today and told them that I needed to have a covered surgery for which I knew there were no surgeons in Massachusetts or even in New England and that I needed to start the process of getting approved for a NETWORK DEFICIENCY. These seem to be the key words to mention. He asked what the surgery was and I told him phalloplasty. He asked what kind of surgery that was and I said that it is a transgender-related surgery. Cue awkward silence……… :o) Oh well. He said: “Um, let me check to see if that’s even covered.” I said: “It is, I’ve checked all 17 codes. I think what I’m really going to need is a case manager to help me move forward, is that something you can help me with?” He said: “Yes, let me work on that for you.”

All in all the phone call was not too bad. I know for me, just working myself up to make these calls can take a lot. Sometimes I’ll think about making a call for weeks (or longer) before I ever do. It can be tough because I know I just expect it to be awkward and uncomfortable. And I just accept the fact that unfortunately I’m going to know a lot more about what I’m talking about than the person that I speak with, and I don’t even know a lot about health insurance… I’m sure that sounds arrogant, but the truth is folks just don’t know the reality of these surgeries or the availability (or rather lack thereof) of surgeons. It can be frustrating trying to get information and help from someone who you know isn’t really clued into the facts, but there’s really no way around it that I know of. So at this point I am waiting to hear back from a case manager and I will update when I know what the next step is.