This work was supported by the Bernard G. Sarnat Endowment for Craniofacial Biology (JCL) and the Jean Perkins Foundation (JCL). Health insurance might not cover surgical procedures considered cosmetic for the cisgender population people whose gender identity matches the one they were assigned at birth even though these procedures are . Error bars denote standard error. Demographic, clinical, and administrative data were retrospectively collected (UCLA IRB #19-001482). In this work, we report the methods, time consumption, costs, challenges, and successes of our institutional experience on obtaining insurance coverage for FFS. Complete New Patient Questionnaire. Average time spent from administrator and surgeon in obtaining insurance approval for FFS (A). JAMA. One of the major barriers for transgender patients is accessibility to gender-affirming surgeries due to the lack of insurance coverage or inability to afford surgery as a self-pay patient.1 In an analysis of the National Inpatient Sample, Canner and colleagues noted that between 2000 and 2014, 56.3% of patients undergoing gender-affirming surgery were not covered by any health insurance plan.2 Over the course of this period, particularly between 2012 and 2014, an increase in patients covered by private insurance and Medicare and Medicaid was noted. Qual Life Res. Wolters Kluwer Health, Inc. All rights reserved. Two letters from mental health providers. In Patient X's case, she has achieved the full extent of facial feminization that can be expected with hormone therapy. FGCS is a collection of procedures designed to change the bone structure of the face and reshape features that resulted from testosterone exposure. Health insurance is unnecessarily difficult when it comes to gender affirming surgery. First, one of the most significant barriers to FFS for patients is the ability to pay for surgery, which ranges from $40,000 upwards for full-face, one-stage surgery. Capitn L, Simon D, Kaye K, et al. Ask them how many FFS surgeries they perform within a year. This is the point at which you will likely need legal support. We believe that for many transgender women, FFS is medically necessary to treat gender dysphoria. Months required for definitive insurance authorization decisions for FFS. Ultimately this letter is between you and your provider, but here is some sample language that has been helpful to patients I've worked with: "Patient X has been adherent to two years of hormone replacement therapy including (specific estrogen regimen.) In the rare instance that FFS Surgery is included in your health insurance policy, services may be incomplete or function only on a reimbursement basis. Woolhandler S, Campbell T, Himmelstein DU. Group B, consisting only of private insurance plans, are processes that initially resulted in denial, thereby requiring multi-level appeals. Facial Feminization Surgery (FFS) is becoming more and more popular, but it can be hard to narrow down the surgeons who best perform these complex surgeries. Thirdly, it is likely that the current work underestimated the total cost of the insurance approval process, as we could not quantify the cost of surgery cancelations, additional clinic visits, and unquantifiable administrative time. They submit their own information, information about the procedure being performed, and information about you. surgical techniques and analysis of results. Plastic and Reconstructive Surgery Global Open9(5):e3572, May 2021. Facial Feminization Surgery provides dramatic changes to the male face which helps facilitate Male to Female (MTF) Transgender patients to fully live in the female role and be perceived as a woman with confidence. In general, patients who undergo FFS will stay overnight after their procedure and return home the following day. Facial Reconstruction: Gender affirming facial surgery is considered reconstructive when all of the following criteria have been met: The individual is at least 18 years of age; and 5. Facial feminisation surgery can involve a combination of all or some of the below cosmetic procedures. Your message has been successfully sent to your colleague. 1) and surveying administrative personnel and physicians to determine the approximate time spent on each step. Dr. Sajan performs the following Facial Feminization Surgery procedures at his state-of-the-art facility in Seattle, Washington. https://links.lww.com/PRSGO/B647.). Both of these methods are. Post Surgery Recovery. In September 2022, WPATH released the Standards of Care (SOC) version 8, for trans and gender-diverse medical and mental healthcare. The lady on the phone told me the surgery usually ranges from $60-100,000 dollars. From the cohort, 3 subgroups were delineated. He has been performing gender surgery since 2005. 2010; 19:10191024. Some error has occurred while processing your request. The concept and treatments were developed with transfeminine patients in mind in the 1980s, led by a San Francisco-based surgeon who devised measurements for a "normal" female appearance by surveying anthropological skeletal records. They will need letters of support from you for the preauthorization, following WPATHs Standards Of Care. In addition to legislative changes, the rationale for increasing coverage may be related to calculations on the cost-effectiveness of coverage. In contrast, FFS under insurance coverage allows for inpatient care, which may be important, particularly to surgeon decision-making as well as patients who may have other medical conditions, pain control issues, or those who travel from long distances. Dr. Mangubat is a board-certified cosmetic surgeon in the Seattle area who has been performing transgender surgery procedures for over twenty years. With a forehead reduction, our aim is to reduce a prominent brow or forehead bossing. Analyses of variance with posthoc comparisons under the Tukey criterion were used to compare time from consultation to approval or denial, time spent obtaining insurance authorization, and cost. Read this first. Available at: 9. Compared with the published literature, patients within Groups B and C are multi-fold greater than the reported standard estimates in the former study without even taking into account time and costs of post-surgical billing activities. Referral letters and supporting documentation should be sent to: UCSF Gender Affirming Health Program 1725 Montgomery St. Suite 250 San Francisco, CA 94111 Phone: 415-885-7770 Fax: 415-353-3399 transcare@ucsf.edu 2003; 349:768775. Search by U.S. State, Procedure and Insurance Search by Country and Procedure Browse the Global Surgeon Maps. Dr. Facque is a board-certified plastic surgeon in San Francisco, California who started providing gender-affirming care in 2012 and has worked exclusively with transgender and non-binary patients since 2020. Dr. Ellie Zara Ley, MD is an accomplished board-certified plastic surgeon who had more than 15 years of specialized training in plastic, craniofacial and micro surgery before learning the art of Gender Confirmation Surgery. Secondly, the current study does not take into account the postsurgical administrative and billing time consumption and costs. However, I personally know multiple people who have achieved coverage for FGCS through state Medicaid in both NY and California. Facial feminization surgery can be covered by health insurance in some instances. How soon can I book a surgery date? Resources in other locations are variable, but I'm attempting a general starter guide to FGCS through insurance. For example, there are now many hospitals across the . He works exclusively with trans women, trans men and non-binary patients seeking gender-affirming surgeries, including Phalloplasty, Vaginoplasty and Facial Feminization. Otherwise, your deposit will be applied towards your surgical balance. P < 0.05 was considered significant. The blossoming of academic medical centers offering transgender surgical care also means that more well respected surgeons, with appropriate craniofacial and maxilliofacial reconstructive training, are able to do procedures through insurance. For people without local connections, the facebook group, FFS Facial Feminization Surgery / Transgender TG TS and the FFS Forums on susans.org are good places to seek community support as well. Facial feminization surgery (FFS) uses a series of procedures to alter features to appear more classically female. Though WPATH has released the new SOC, it will take insurance companies time to evolve. 2014; 134:609619. FGCS is a treatment for gender dysphoria related to the secondary sex characteristics in the face, not a treatment for anxiety caused by the experience of having gender dysphoria or being a transgender person in an unkind world. Americans who are considering surgery as part of their transition can find the cost of gender-affirming surgery to be steep. For both Groups B and C, the authorization process averaged approximately 6 months, a 6-fold increase compared with Group A. (See table 2, Supplemental Digital Content 2, which displays the total time and cost of the insurance approval process per group. The time from initial consultation to final insurance denial required 5.1 0.7 months, nearly 5-fold higher than Group A (P = 0.003) (Fig. Surgeries are performed by our world experts in facial reconstructive surgery, including: Drs. Only patients with insurance authorization decisions were included in this study (n = 40). 8. Every insurance company is "difficult" to work with. I always advise people to try with the insurance they have before they switch to another plan. Facial feminization surgery (FFS) encompasses a series of surgical interventions designed to make your face appear more feminine. https://links.lww.com/PRSGO/B648.). The United States . Surgery Scheduling, Rescheduling and Cancellations: Oakland Head and Neck . To filter results, enter information and 'click search icon' and/or select from the dropdown lists. Doctors and nurses take good care. Dr. Mangubat specializes in Top Surgery, Breast Augmentation and Body Sculpting, Gender Confirming Facial Surgery and Hair Grafting. Also known as facial feminization surgery or FFS, this is a general term for a group of procedures designed to change the bone structure . Please enable scripts and reload this page. Furthermore, revisions may be indicated in some patients over time. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. William Hoffman, MD and Jason Pomerantz, MD from the UCSF Division of Plastic Surgery, and Drs. The average cost of facial feminization surgery (FFS) is $34,504, according to 213 reviews from RealSelf members. I recommend the pioneer of FGCS, Dr. Douglas Ousterhouts book, Facial Feminization Surgery: A Guide for the Transgendered Woman for those looking to learn more about what skill and training is involved and a breakdown of procedures as he performed them, but Ill attempt to summarize. The standard premium for Medicare Part B in 2020 is $144.60 each month, and there is a $198 annual deductible cost. In this work, we detailed our institutional experience on obtaining insurance coverage for FFS. Thus, coverage significantly increases accessibility. San Francisco, CA 94108. You need an understanding of your insurance benefits in general: What would any covered surgery cost you? We're gonna try really hard to get my insurance to cover it, but I'm not holding my breath. may email you for journal alerts and information, but is committed 6. 2015; 136:560e561e. On average, Dr. Keojampa is booking 8-12 months out for Aesthetic Craniofacial Surgery and Facial Feminization Surgery. Try your local trans advocacy groups, LGBTI legal services, support group, etc. Bottom surgery, or changing the genitalia, costs an estimated $25,600 for male-to-female patients and about $24,900 for female-to-male, according to The Philadelphia Center for Transgender. Recognized for his exceptional surgical skills and natural-looking results, Dr. Raminenis patients also praise his friendly, compassionate and professional nature. Each patient is different and your expectations and desired results will be discussed fully in your consultation. I could go on about this, but I hate to further the expectation that you must be very mentally ill in order for the "extreme" treatment of FGCS to be warranted. https://links.lww.com/PRSGO/B648.). His experience in cosmetic and craniofacial surgery makes him an excellent choice for Facial Feminization (FFS) and Masculinization surgeries. Second, while complications are not high in FFS, they may occur. Facial feminization surgery (FFS): The permanent . They accept most major insurances and work to help you get your surgery fully covered whenever possible. If it is substantial, they should name their years of experience working with transgender patients. Upon receipt of a deposit for your surgery, our practice may offer to submit a prior authorization request to your insurance provider. The administrator hourly compensation set at our institution was used for the cost analysis. After a person pays the deductible, Medicare pays 80% of the allowable costs . Submission and review of second level, patient-initiated appeal (1 month); 4. Dr. Schnitt is a board certified cosmetic, plastic, reconstructive and craniofacial surgeon who has been practicing in South Florida since 2002. During his plastic surgery residency, Dr. Esmonde worked in the Transgender Health Program at OHSU. Dr. Esmonde is a plastic surgeon in Portland, Oregon who has extensive knowledge about Gender Affirmation Surgery and works almost exclusively with transgender and non-binary patients. One of the major issues among surgeons and patients with regard to insurance coverage for FFS is the lack of understanding of the process as coverage for gender healthcare is highly variable depending on state law and plan variabilities (Table 3). There is also a great deal of discussion on various internet forums and also on social media in terms of how to reduce the cost of your facial feminization surgery by claiming the procedure on your health insurance. Most other insurance plans do not cover FFS and consider it as cosmetic surgery. Plans that fall into this group include Medi-Cal, Medicare, and some private insurance plans. Days, a 50-year-old Berkeley resident, had just returned from a month-long trip to Spain in February, where she underwent a procedure known as facial feminization surgery, or FFS. Which, though I knew FFS is expensive, is a bigger estimate than I've ever seen for the procedure. In NY, we have the benefit of a clear history of coverage through Medicaid, and plenty of pro-bono legal teams able to help patients with denials. Error bars denote standard error. The multi-level appeal process included physician-initiated appeal, patient-initiated appeal, and independent medical review (IMR). This could be replaced with language about how you are not eligible to take estrogen therapy for whatever reason, including fancy language for just not wanting to. Dr. Crane is a board-certified plastic surgeon who performs Gender Affirming Surgery procedures in Austin, Texas. Facial feminization is the term given to a collection of procedures designed to make facial features more feminine. Insurance Coverage for FFS Surgery abroad Medical inequality for trans people means that access to quality trans healthcare is absent or limited in many regions. Facial Gender Confirmation Surgery or Facial Feminization Surgery (FFS) is a technique utilized to change masculine facial features into softer feminine ones. Each letter should state "this procedure is medically necessary treatment. With all letters, I advise providers to be as authoritative in their tone as possible, and to explicitly claim an expert status if appropriate. Also referred to as Facial Gender Confirmation Surgery (FGCS), these procedures are becoming more and more popular, and increasingly are covered by insurance. He serves as Division Chief of Plastic & Reconstructive Surgery at Rush University Medical Center in Chicago, and Program Director of the Plastic & Reconstructive Surgery Fellowship. He is also skilled at multiple techniques of Top Surgery, Breast Augmentation and Body Sculpting. Surgery will be carried out under general anaesthetic and can typically range from around 4 to 8 hours depending on the procedures. a support group of people dealing with similar issues to you to help keep up your strength and spirits throughout planning and recovery. The differences between male and female facial features vary with age, ethnicity, and how early hormonal therapy began. 14. Ann Plast Surg. This is their communication with the insurance company verifying that the procedure is covered. Gray R, Nguyen K, Lee JC, et al. This could include either shaving down or entirely re-contouring the forehead/eyesockets/sinus area using osteotomies (cutting and repositioning bones), shaving the jaw line or a sliding genioplasty (reduction and/or re-positioning of the jaw bone), lifting the upper lip, rhinoplasty (nose job), and bringing the hair line further forward, in addition to other various soft tissue facial adjustments and reduction of the adams apple. Surgeons who practice facial gender confirming surgery often have special training in reconstructing facial features using bone grafting beyond a traditional plastic surgery residency. Dr. Hadeeds practice now has two locations: Beverly Hills, California and Miami, Florida. These delicate procedures change the male facial patterns to a softer, feminine appearance. It is of great importance to note that there is no one-size-fits-all solution for facial gender affirmation with respect to determining medical necessity of procedures. From the *Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, Calif. UCLA Gender Health Program, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, Calif. In these circumstances, both complications and revisions are covered as reconstructive procedures, whereas self-pay patients may be responsible for secondary surgical costs. Historically, FFS hasn't been covered by health insurance or government healthcare. 2016. Facial Feminization Surgery: A Guide for the Transgendered Woman. Additionally, planning and recovering from any trans surgery is hard! Most trans women elect to have all facial feminization procedures performed at once, or in two phases (upper face and lower face). Location: Bangkok, Thailand. In total, the time and cost estimate of the insurance appeal process was 10.8 1.0 hours and $855.00 91.53 per patient, respectively. Based on my conversations with friends who are very satisfied with their FGCS, I assure you that no surgery can completely resolve that anxiety. The structure of this system sucks, but it's the one in which you find yourself and it is your responsibility to make it work for you. Modeling performed by Padula and colleagues for employer-based insurance plans in Massachusetts indicated that, over the course of 5 years, coverage for transition-related services would lead to societal costs of $0.016 per month per member.3 The authors concluded that the relatively low societal cost, combined with the increase in quality-adjusted life years for transgender patients, supported coverage of transition-related services in employer-based plans. Dr. Meltzer is a plastic and reconstructive surgeon who has been performing Gender Reassignment Surgery since the early 90s. Forehead (frontal bone recontouring, recontouring of superior orbital rim, hairline lowering). In addition to administrative time, multi-level appeals required time from the attending craniofacial surgeon for peer-to-peer reviews, writing appeal letters, and patient counseling over the 6-month period, in total averaging 3.6 0.5 hours per patient. 2010; 170:17281734. By browsing TransHealthCare.org, you consent to our use of cookies and other tracking technologies. Received for publication February 2, 2021; accepted February 27, 2021. Get a bossy friend to make phone calls with you while you are dealing with the process. What's your out of pocket max? These are usually self-insured employer plans which are administered by well-known insurers such as Blue Cross Blue Shield, United Healthcare, Harvard Pilgrim Healthcare, and Tufts Health Plan. This study highlighted the successes and burdens associated with obtaining insurance authorization for FFS. However, California state law stipulates gender non-discrimination in health insurance, thus, Medi-Cal covers all procedures performed specifically for the purposes of gender affirmation. Subsequently, the process typically follows one of three paths: Group A (standard approval), Group B (extended approval), and Group C (denial). Temporal trends in gender-affirming surgery among transgender patients in the United States. Some people stress additional mental health conditions (anxiety, depression, ptsd) in these letters. A second subgroup of patients (Group B), all of whom had private insurance, were approved for surgery but required multi-level appeals, peer-to-peer discussions, and, ultimately, an IMR. In addition to performing hundreds of gender-affirming procedures each year, Dr. Rumer also directs a 1-year gender surgery fellowship program. Dr. Hadeed is a board-certified surgeon who specializes in Transgender Surgery, including chest/breast procedures, facial surgeries and body sculpting for both trans men and women. You need to come in for an in-person consultation AND pay a deposit to secure your surgery datebeforewe will submit for prior authorization. 2). Facial Feminization Surgery (FFS) is a group of facial procedures that alter the face to create more classically feminine characteristics, such as a higher brow, a more refined feminine nose, and less pronounced Adams apple. Please note that before you can schedule . Our practice does NOT contract with any insurance providers to allay the cost of your facial feminization surgery. N Engl J Med. Next, you want an awareness of any explicit inclusions or exclusions for transgender care in your "Certificate of Coverage," the document that lays out what is covered in what circumstances. As many professions say, past performance does not guarantee future results. However, the tide of change is beginning to roll in- often where Medicaid begins, private plans will be forced to follow, so the clear coverage in California and New York bodes well for everyone. 2018; 319:691697. 1. FFS may include a brow lift, cheek augmentation, rhinoplasty, and lip augmentation. We are looking forward to meeting you in person, hearing your aspirations, and tailoring a Surgical plan especially for you. Because the plastic surgeon is not paid on an hourly or salary basis, the national average salary was used.8,9 The estimated cost of the insurance process per patient was calculated by combining the hours spent per step and compensation rates. Surgical Staff: 13 surgeons, each specialized in surgery ranging from plastic to maxillofacial surgery. The cheapest caesarean section is 48,000 baht (year 2020) including sterilization 53,000 baht. If your insurance provider approves the authorization request, we may be able to submit a one-time complimentary claim on your behalf. Furthermore, even in the challenging scenario for insurance authorization reported by Braun and colleagues, Groups B and C also exceed reported estimates. The surgeons listed below are highly qualified plastic, reconstructive, craniofacial, maxillofacial and cosmetic surgeons who offer gender-affirming facial surgery. 2. A prior authorization is not a guarantee of payment, therefore, you should have funds available to cover all fees and costs related to your surgery should your request be denied. These issues will remedy themselves as you heal, but will often require several weeks to completely resolve. All data were analyzed using SPSS software, version 25 (IBM, Chicago, Ill.). Dr. Ramineni is a board-certified plastic and reconstructive surgeon with over 15 years of experience. Coordinating presurgical authorization required an average of 7.8 1.5 hours per patient for the administrator and 4.3 0.5 hours per patient for the attending craniofacial surgeon to navigate multi-level appeals. Read your cover in detail and find out the following: Second, find out if yourCertificate of Coveragehas any inclusions (or exclusions) around transgender care. We recommend you take at least two weeks off from work to recover, but expect up to six to eight weeks of decreased activity. Male-to-female (MTF) facial feminization. Notes. Dr. Salgado is a board-certified plastic surgeon with deep expertise in gender-affirming procedures. Lastly, a third subgroup of patients (Group C), all with private insurance, were denied for surgery despite multi-level appeals, peer-to-peer discussions, and IMR. Leigh JP, Tancredi D, Jerant A, et al. (link is external) for CGSP. Specific surgical procedures were requested based on patient desires and clinical assessment, with the goal of completing FFS in a one-stage surgery. James S, Herman J, Rankin S, et al. Publications See a list of publications about facial feminization by Mayo Clinic doctors on PubMed, a service of the National Library of Medicine. If performed all at once, FFS usually takes between 4- 8 hours. generic exclusions referenced under "general surgery guidelines" and "cosmetic procedures." South Dakota (0) State Medicaid has no . 3. These IMRs are often requested through the California Department of Managed Healthcare resulting in state-mandated overturn of the insurance decision, or less commonly, through the insurance company for ERISA or self-insured plans which do not fall under state jurisdiction. However, its important to be aware that the terms and conditions of many insurance policies do not recognize coverage for the cost of FFS, or may exclude coverage for the services provided to you. Before getting into the nitty gritty details, let me be real with you, and let me be hopeful. Top facial feminization surgeons will typically undertake 2-3 facial full feminization procedures a week, this equates to at least 100 or more a year. Some will result in eventual approval (Group B) and others will result in eventual denial (Group C). As an example, the typical timeline for our Group B and C patients is as follows: 1. He currently performs approximately 200 genital reconstruction surgery cases per year in Scottsdale, Arizona and Portland, Oregon. Medi-Cal, the California state equivalent of Medicaid, authorizes all gender-affirming surgeries including FFS and Medicare does not require prior authorization. to maintaining your privacy and will not share your personal information without Dr. KathleynBrandstetter. Which, though I knew FFS is expensive, is a bigger estimate than I've ever seen for the procedure. 2020 Deschamps-braly clinic. It is important to be aware of the side effects that will certainly occur, like swelling, bruising, and incisional scars. (See table 1, Supplemental Digital Content 1, which displays requested CPT codes and associated terminology for facial feminization surgery. The FFS Surgeons listed below are highly qualified plastic, cosmetic and maxillofacial Surgeons who regularly perform FFS. Hormone therapy alone has not sufficiently treated her gender dysphoria, and the next step in her treatment plan is Facial Gender Confirming Surgery." As gender dysphoria is highly individual, such procedures will vary by anatomical areas associated with dysphoria for each individual patient as well as decision-making from the treating surgeon. In total, the time consumption of the insurance process was 12.0 1.6 hours and cost $988.38 101.76 per patient.

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