Gender Confirming Surgery Covered By Medicare

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AMA, American Psychiatric Association, California, Colorado, Connecticut, District of Columbia, Fortune 500 companies, FTM, gender confirming surgery, health insurance, HHS, Massachusetts, Medicaid, Medicare, MTF, Oregon, private insurance, San Francisco, Sex reassignment surgery, Social Security Administration, transsexuals, Vermont

About two months ago, the Social Security Administration announced a policy change that Medicare will now cover the costs of gender confirming surgery as part of the treatment of transsexuals.  Previously, Medicare would not cover such costs on the grounds that such surgery was considered ineffective in treating the condition, and amounted to little more than elective cosmetic surgery.  Growing evidence to the contrary as recognized by the recognized medical community was cited as the main reason for the reversal of the previous policy that had been in place for 33 years.

While a number of transsexuals at or near the age of Medicare eligibility will benefit from this new policy, it can be expected that the number of those using Medicare to pay for the surgery will dwindle over time.  As social stigma towards transsexuals wanes and transition occurs more frequently at younger ages, it will not be long (perhaps 10-20 years) that most transsexuals will have the surgery, if they elect to have it, long before they reach Medicare age.

In fact, the new policy will help to make that a reality.  It is likely that the longer reaching effect will be outside of Medicare.  With the endorsement of a Federal agency that this surgery is a necessary part of the treatment of transsexuals, backed by the opinion of the AMA, APA and many other respected medical organizations, it will be very difficult for private insurance companies to successfully deny coverage for the surgery unless they specifically redline the procedure.  Most policies are written to cover any treatments that are deemed medically necessary.  We have reached the point where that is now the accepted expert opinion.

I waited awhile to post this news on my blog because I wanted to see what the fallout of the decision would be.  As I expected, there has been very little.  There are a few reasons for this.  First of all, despite hand-wringing in some quarters that the growing acceptance of transsexuals means that the barbarians are at the gate and civilization as we know it is doomed, there simply are not that many transsexuals in the United States to make much impact on the overall society.  (The estimate is 0.3% of the adult population.)  That also means that the number of us who will be taking advantage of this new benefit will be small, even in the peak years.

A few years ago, the City of San Francisco included coverage of this surgery as a medical benefit for their employees.  Their insurance carrier did a survey to find out the number of transsexuals employed by the city.  They then raised their premiums accordingly.  They made a substantial profit as a result.  They made the assumption that every transsexual on the payroll would jump to have the surgery.  But it wasn’t so.  First of all, not every transsexual wants the surgery.  Some elect to remain non-op for various reasons: some expect to remain that way for a lifetime while others may choose it for an indefinite period.  A great many FTM transsexuals decline the surgery simply because it does not produce a very realistic or functional result.  While the surgery produces far better physical results for MTF’s, there are still a significant number who wait or refrain from the surgery.  Accommodating the needs and desires of a spouse or partner is one reason.  Personal sexual preference is another.  Recent trends of younger transgender persons toward gender fluidity and away from a gender binary would be the rationale for others.  General health issues or concerns about undergoing surgery are still more reasons.

We also will not see much impact from this decision unless a case becomes public where a transsexual challenges the decision of her insurance carrier to deny coverage for the procedure.  There were some stories about these challenges being successful prior to Medicare’s decision to change the policy.  If insurance companies are falling in line on this issue and not denying coverage, that will not be newsworthy.

Finally, we have yet to see whether Medicaid will make the same change in policy.  Especially in those states where expanded Medicaid is in place, that could be a far more significant change.  Medicaid covers a broader and generally healthier age range than Medicare.  Even so, the tiny percentage of transsexuals in the population will mean very little financial impact by this decision on the system.

There are already five states (California, Colorado, Connecticut, Oregon and Vermont) plus the District of Columbia that also affirm that gender confirming surgery can be a necessary part of treatment.  Initiatives have been sponsored by the Governor of Massachusetts to join the list.  There is also a growing trend for private corporations to cover the surgery.  A recent survey of Fortune 500 companies showed that 28% now cover it.  None did in 2002.

So far Medicaid in only three states will pay for the surgery: California, Massachusetts and Vermont.  At the moment, Medicaid coverage is occurring on a state by state basis.

Does this mean that a person on Medicare can simply find a surgeon who specializes in these procedures and arrange for surgery and Medicare will foot the bill?  Absolutely not.  Each patient will still need to go through the appropriate procedures of diagnosis and receive a recommendation by qualified members of the medical community before such surgery can be considered medically necessary.

Here are links to two stories written immediately after the decision was announced, covering different angles on the topic.

http://www.washingtonpost.com/national/health-science/ban-lifted-on-medicare-coverage-for-sex-change-surgery/2014/05/30/28bcd122-e818-11e3-a86b-362fd5443d19_story.html

http://bigstory.ap.org/article/medicare-coverage-ban-sex-change-surgery-lifted

Submit yourselves to every ordinance of man for the Lord’s sake: whether it be to the king, as supreme; Or unto governors, as unto them that are sent by him for the punishment of evildoers, and for the praise of them that do well. For so is the will of God, that with well doing ye may put to silence the ignorance of foolish men: As free, and not using your liberty for a cloke of maliciousness, but as the servants of God. Honour all men. Love the brotherhood. Fear God. Honour the king. – 1^st Peter 2:13-17

God bless,

Lois

My Ongoing Obamacare Nightmare

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ACA, application, bureaucracy, bureaucrat, Federal Government, government, Health Insurance Exchange, income tax return, incompetence, Internal Revenue Service, IRS, Medicaid, net income, New York State, nightmare, Obamacare, Obamacare nightmare, Patient Protection and Affordable Care Act, privacy issues, proof of income, self-employed, self-employment income, Social Security Administration, Tax return (United States), United States, verification of income

Back in November, one of my clients asked for help with his Obamacare application.  Like me, he is both a New York resident and has self-employment income.  It would be a good learning experience for me, as I would be putting in my own application soon.  I found the New York health exchange easy to use, living up to the early reviews that it was far superior to the severely flawed Federal website.  It was very responsive each time we clicked on a link and soon we had a completed application except for the choice of plan.

A few weeks later in early December, I confidently ventured onto the same site for my own application.  Once again, entering personal data was quick and easy.  Then it came time to answer the income question: did I expect my 2014 income to be the same as in 2012?  And here was where the nightmare began.

When my client reached this question, he answered “yes”.  Apparently this government agency has access to your 2012 income tax return, but hey, no privacy concern there, right?  Anyway, that answer bypassed a number of additional steps and questions, as I was to find out.

My answer to this question was “no”.  While I did have a net loss of clients in 2013 (some related to my transition and some not) and some associated loss of income, the major reason for a decrease in income was that I had a project in 2011 for which I was able to charge about twenty times my usual average fee.  Three-quarters of my fee had been paid in 2012.  It is highly unlikely that this type of work will come my way again.

To be expected, I was taken to pages on the site to provide my estimated 2014 income.  Unexpectedly, this was where things started to fall apart.

First of all, it did not want to take my income as a self-employed individual.  I found I was only able to enter it if I said that I was an employee of my own company.  A further complication came because it was insisting that I provide data for my last three months of income and expenses.  As a tax preparer, providing my income and expenses for September-November would have vastly understated my net income.  There seemed to be no understanding that some people have seasonal businesses.

But the biggest problem of all was that the site kept timing out on me and returning me to an earlier screen.  I type rapidly and had all the information at my fingertips.  There was no significant delay in my data entry that should have caused this error.

Admitting defeat, I reluctantly called their help line number.  Soon, I was speaking to a capable agent who was more than willing to enter the information that I gave her.  In minutes, I felt vindicated.  She was getting the same time out problems.  Soon, we reached a point (about our fourth or fifth try), where she said that we would try it one more time and if it didn’t work she was going to call tech support.

For some reason, this time it worked.  It was like the Dilbert cartoon where the pointy-haired boss is telling Dilbert that he keeps clicking on a link and it doesn’t work.  Just as Dilbert starts to quote the line that insanity is doing the same thing over and over and expecting a different result, the boss clicks again and it works.

So now all the income and expense data is entered.  At this point, she tells me that we cannot proceed any further as they want verification of the financial information I just provided.  Thinking quickly, I ask her what will be acceptable as verification.  I know this might be a problem as my business income comes in the form of about 80 checks a year from almost the same number of individuals.  None of them are required to issue me a 1099.  And there is little reason for me to incur the cost of a separate business bank account, so I don’t have one.

She replies that this is outside of her area, but that in about 7-10 business days, I should receive an e-mail providing this information.  Unfortunately, I received no such e-mail and that time frame took me to December 23, the original deadline by which you had to have completed your application to be covered by January 1 (which they magnanimously extended one day).  There was no way I was getting through on the phone then.

So I called back between Christmas and New Year’s Day.  This time, I got an all too familiar government bureaucrat bozo.  When I asked what I could use as verification of my income and expenses, he replied to my amazement, “We don’t tell you what to send.”

Keep in mind that I worked for HUD for three years, a local housing authority for four years, and then was a stock broker for over twenty years which meant that my activities ultimately came under regulation by the Securities and Exchange Commission of the Federal Government (and I had to know those regulations to pass my licensing exam).  And for the past twenty-five years, I have dealt with the IRS, the NY State Department of Taxation and Finance, and New York’s counterparts in a few other states in my work as a paid tax preparer.  Finally, as part of my transition, I needed to know Social Security Administration and NY Department of Motor Vehicles verification requirements.  Never has there been a time when there were not clear regulations on what could be used as verification of statements made on an application.

Even so, I had no basis on which to argue with this agent.  So I am trying to figure out what I can use as verification.  Making a spreadsheet of my income and expenses would have been easy.  But I dismissed it as self-serving.  Anyone could type numbers and descriptions into Excel without a shred of truth in it.

What followed was Kafkaesque with a touch of Seinfeld plot line.  The results were as poor as could be expected under such circumstances.

There was only one way that came to mind as to how I could verify my income in 2013 as being less than in 2012: bank statements.  My bank statements for each year would show that the deposits in 2013 were less than in 2012 (by the differential I had stated in my application).  I was able to download monthly bank statements online from my bank account in a format that was acceptable for uploading to my Obamacare application.

However, there were three problems with this method.  The first was the amount of documents I would need to send.  My bank’s website did not provide a filter so I could retrieve only the deposits.  So I had to upload the entire bank statement.  Twenty-four months’ worth of bank statements at three pages each would mean a lot of pages for some bureaucrat to review.

The second problem was directly related to my transition.  Knowing who I might be dealing with, I wanted to make it as foolproof as possible.  The name on the account in 2012 did not match the name in 2013.  I could not count on the reviewer noting that the account number did not change.  So I uploaded a cover letter with an explanation and also uploaded my name change documents.  Now some reviewer has an awful lot of information about me.  I could just see him or her calling over another reviewer: “Get a load of this person’s application!”

Finally, there is the fact that deposits show income but not expenses.  And while 99% of my deposits are business-related, many of the expenses are for personal items.  I explained that the expenses are independent of income and are basically the same from year to year.  Since the expenses are approximately the same in 2013 as in 2012 (which information they already had), the deposit differential is essentially the same as my decrease in net income.

I was able to upload all this in the first week of January.  And then I waited, and waited and waited some more for the great State of New York to reply.

Knowing I would be getting much busier over the next two and a half months, I called back at the end of January.  I figured that four weeks was enough time to expect my information to have been reviewed.  This time, the person on the other end of the phone was very competent in her job.

She noted the large number of documents that I had uploaded and said it would take a few minutes before they would all be available.  While we waited, I was able to ask her a few questions about Medicaid and how it worked.  Finally, she told me that she was able to see on her screen that they were in the process of reviewing my documents, which means they should be finished soon.

And soon they were: the documentation I supplied was not considered sufficient proof of my self-employment income.  When I received a hard copy of this notice, it came with a document that set forth all the acceptable means of verifying any statement you might make on your application: the very information I was unable to receive a month earlier.  They wanted more hard proof, not just my statement that expenses were unchanged.

So I did something that I hadn’t done for at least 30 years (since becoming self-employed made my tax return more complicated), if ever.  I was preparing my own tax return at the beginning of February instead of working on my clients’ returns.  And as soon as I learned that my e-filed return had been accepted by the IRS, on February 11, I submitted my entire, five page, 2013 Federal Income Tax return as my most up to date proof of my income and expenses.  And I sent a copy of the proof that my e-filed return had been accepted).

I went back to the waiting game.  Around March 18, I called.  It was another trip to Bozoland.  First, he told me that they hadn’t even started reviewing my latest submission.  Okay, there’s nothing he could do about that.  But then he made the most ridiculous statement.  I mentioned the irony that I would have qualified for Medicaid using the income on my 2012 return.  (I was told this by the competent agent on my previous call.)  His response?  He actually told me that you don’t apply for Medicaid through the website that I was calling about!  Since the client I had helped months earlier had his Medicaid benefit card by now, I knew this was patently absurd.

By the time April 15 came and went, I still had not heard anything.  As it turned out, my health care nightmare was only beginning.

Praise God that for those of us who are in Christ, we are only sojourners here and we have a better country to look forward to.

And he shewed me a pure river of water of life, clear as crystal, proceeding out of the throne of God and of the Lamb. In the midst of the street of it, and on either side of the river, was there the tree of life, which bare twelve manner of fruits, and yielded her fruit every month: and the leaves of the tree were for the healing of the nations. – Revelation 22:1-2

God bless,

Lois

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How to change your gender marker with the Social Security Administration

Tags

gender transition, Identity document, Medicare card, passport, Social Security, Social Security Administration, Social Security number, SS-5 form, SSA, State Department, Transition, Transsexual

In January, a commenter on another website mentioned that she was not able to change her gender marker with Social Security.  When I replied that the Social Security policy had changed, she asked for help on how to proceed.  My original reply was not accepted, possibly because of length or because a URL was included.  My condensed version was posted.  Here is the full version.

Some transsexuals in the United States who changed their Social Security information before the spring of 2013 are not aware that the regulations have changed regarding changing your gender marker in the Social Security records.  Previously, evidence of surgery was required by SSA to change the gender marker. That policy was changed in June 2013 so there would be consistency between SSA policy and State Department policy, which did not require evidence of surgery to use your preferred gender marker on your passport.

I had my name changed with Social Security immediately after the court approved my application for a legal name change.  That was in January 2013.  When I went back to my local Social Security office this past November, I had to school them on the new policy. But the clerk checked with a supervisor and five minutes later they processed my gender change without another hitch.

Social Security is a Federal agency, so they have access to the same regulations no matter which office is closest to you.  It is your right to do this no matter where you live.  So go for it.  Here are some steps you can follow to expedite things:

>> To save time, go to www.ssa.gov and retrieve Form SS-5. It is the form that is used to either apply for or change info related to your Social Security card/account. It is a fill-in form so you can fill it out online and either save it to your computer or print it (but be aware that unless you only select the form page, you will also print out all the instructions). Or you can print or save the blank form and fill out offline. Whichever you find easier or you prefer.

Entering your social security number with the fill-in function is a bit tricky. Even though there are individual boxes for each number, you cannot tab from box to box. You have to put your cursor in the left hand box and type your first three numbers. Then tab and type your next two numbers. Tab again and type the last four numbers. Okay, you got past that item.

Number 8 (Sex) is the key item for our purposes. Check the box that applies to you now.

>> You will also need to bring the following items with you:

— Gender (You need one of the following documents; a full-validity,10-year U.S. passport showing the new sex; a state-issued amended birth certificate showing the new sex; a court order directing legal recognition of change of sex; or a medical certification of appropriate clinical treatment for gender transition in the form of an original letter from a licensed physician). The document must have enough biographical data (e.g., name and date of birth) to clearly identify you;

— Identity (see below*);

— U.S. citizenship (if you have not established your citizenship with Social Security); and

— SS-5 form (unless you want to fill it out and complete it there)

* Here are the documents you may use to prove your identity:

The SSA will accept only certain documents as proof of identity. An acceptable document must be current (not expired) and show your name, identifying information (date of birth or age) and preferably a recent photograph. A birth certificate is not a form of identification. As proof of identity, Social Security must see one of the following primary evidence documents:

— U.S. driver’s license;

— U.S. State-issued non-driver identification card; or

— U.S. passport.

If you do not have one of the above specific documents or you cannot get a replacement for one of them within 10 days, SSA will ask to see another document, such as your:

— Employee identification card/badge;

— Health insurance card or Medicaid card (not a Medicare card);

— U.S. military identification;

— U.S. Government identification card;

— Certificate of Naturalization;

— Certificate of U.S. Citizenship

— U.S. Indian Tribal card (Social Security has to approve as an acceptable ID);

— Certified copy of a medical record;

— School identity card, certified record, or transcript (current year); or

— Life insurance policy.

All documents must be either originals or copies certified by the issuing agency and must (unless otherwise indicated) have been issued within the last two years. SSA cannot accept photocopies or notarized copies of documents. SSA may use one document for two purposes. For example, SSA may use your U.S. passport as proof of your citizenship and identity.

While you are on the Social Security website, type “gender” in the search box.  “How do I change my gender on social security records” is currently the fourth item from the top.  It is where I printed out the list of items you need to bring with you (except for the proof of identity items – that was the answer to a separate FAQ).  It appears to be FAQ 160 in their system.  You might want to print out a copy of the page and bring it with you.  The clerk still may want to double check with a supervisor, but it should add to your credibility.

You’ve gone through a lot to be entitled to that new gender marker.  This is one more step that can be accomplished to affirm your true identity.  It is your right to do this.  Now you know how.

Ain’t no stoppin’ us now!

https://www.youtube.com/watch?v=lRNEzzN-gTo

God bless,

Lois

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