Does HIF cover sex reassignment surgery (SRS)?

We sure do. As with all medical procedures, HIF can pay a benefit on SRS in instances where benefits are also payable by Medicare. Essentially, any medical service listed under the Medicare Benefits Schedule (MBS) can be covered by private hospital insurance. HIF’s eligibility to cover SRS will therefore depend on the treatment involved and the MBS item codes used for the inpatient admission.

For example, if the patient is taking out private hospital cover for the first time and they’re eligible to receive benefits for SRS, a 12 month waiting period will apply. However, if the patient already holds an equivalent level of cover with another fund and switches to HIF, we’ll automatically honour their length of membership and waive any waiting periods already served for SRS procedures.

Also, if the patient chooses a surgeon who has opted in to HIF’s ‘AccessGap’ arrangement, then the benefits payable will be higher due to the AccessGap Cover ensuring a reduced out-of-pocket expense (gap). A full list of providers who have opted in for AccessGap is available on this webpage

Category: Hospital Cover
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Comments

Charly Morris posted at 9:09 PM 06-Jul-2017

Hi there - the above only details male to female sexual reassignment surgery. It should include the procedures (i.e top surgery - double mastectomy) that are covered for transmen - female to male. Gender transition is not synonymous with trans women. Please update your information in this post so it doesn't exclude half of the transgender community please.


HIF Official Response

Hi Charly, thank you for your comment.

With regards to the information in our response dated 30 December 2016, please note that the item numbers listed there reflected just a few examples of SRS procedures as per a previous estimate that was requested by one of our members. It wasn’t our intention to make other readers feel excluded though, so please accept my sincerest apologies if that’s how our response made you feel.

Regarding SRS procedures, please rest assured that we’ll certainly pay a benefit on any medical procedure provided that it: (a) is listed on the Medicare Benefit Schedule; (b) has a Medicare item number; and (c) isn’t defined as an excluded service on a member’s specific policy.

I hope that helps to ease any concerns you may have had, Charly, but please don’t hesitate to get in touch if there’s anything else I assist you with. You can email me any time on social@hif.com.au :)

Kind regards,

Kelsey

concerned mtf posted at 9:40 PM 29-Dec-2016

This does not mean that you will cover SRS, "HIF can pay a benefit on SRS in instances where benefits are also payable by Medicare". The fact you don't even seem to know what it is bothers me too, "HIF’s eligibility to cover SRS will therefore depend on the treatment involved"; SRS is SRS, it's the surgical correction of ones genitalia, to match ones gender identity. Also, I've searched the MBS, and SRS/sexual reassignment surgery doesn't appear at all. So will you actually, definitely pay a claim for this procedure, or not?


HIF Official Response

Hello and thanks for getting in touch.

As with all health funds, HIF can only pay on medical procedures that are also payable by Medicare and have a valid MBS item number.

In order to undergo SRS, the pre-surgery process is quite complex, starting with a GP visit to get a referral to see a specialist. I believe SRS also requires the patient to undergo psychiatric and hormone assessments prior to any surgery being done and there may also be a requirement to speak to Medicare directly to confirm eligibility for the procedure. The specialist will provide a written estimate which details the Medicare item numbers for the procedure plus their own fees.

Once eligibility is confirmed for the surgery and a decision is made to proceed, that’s when we recommend that our members contact HIF to discuss the surgeon’s fees and potential out-of-pocket expenses. Once HIF has the Medicare item numbers and the specialist’s charges, we can generate a Medical Benefit Estimate detailing the rebates you that can be claimed back from HIF and Medicare, plus any out-of-pocket expenses (“medical gap”) which is the portion our member will need to pay.

SRS is covered on a number of HIF Hospital policies. You can view all our Hospital Cover options here in case that helps: http://www.hif.com.au/hospital

In terms of the types of SRS procedures we cover, here are some items that we recently estimated on for an existing HIF member, just in case it helps to provide more context:
• Medicare item #37405: PENIS - complete or radical amputation.
• Medicare item #37342: URETHROPLASTY - single stage operation.
• Medicare item #35565: VAGINAL RECONSTRUCTION for congenital absence, gynatresia or urogenital sinus
• Medicare item #30644: EXPLORATION OF SPERMATIC CORD - inguinal approach, with or without testicular biopsy and with or without excision of spermatic cord and testis on a person 10 years of age or over

At this stage, it’s important to note that SRS is classified as a “pre-existing condition” so a 12 month waiting period does apply. That means that a member would need to be covered for the procedure for a minimum of 12 months prior to undergoing the surgery (this is an industry standard across all Australian health funds). However, if an equivalent level of cover is already held with another fund which includes coverage for these types of services and the member switches to HIF, we’ll automatically honour length of membership with previous fund and waive any waiting periods already served for SRS procedures.

I hope that helps to provide more clarification, but if you have any further questions please don’t hesitate to ask.

Thanks and warm regards,

Kelsey.

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