Medicare Question & Thank You

[passionatedoer]

Hello Everyone,

THANK YOU

You’ve been a great source of information and encouragement to me. I’ve read EVERY thread (476 pages) in the last six months. Getting your body surgically changed forever is no easy decision to make.

But your help is always available. Random stranger: thank you so much.

I’m 38, built like a Greek God and agile. However, my penis has a brain if its own, a dead one. It won’t get up, especially when it’s required to.

I have Medicare.
It says “Medi-Cal Managed Care Health Net (DHS)”

I have FIRMLY decided to get an implant. I talked to a doctor and found out that they don’t accept Medicare as it’s “Out of Network”.

The hospital he works at/with has offered to break the money into 12 payments.

However, in case of emergency/infection , we’re not sure who pays: do I pay or do I need insurance?

Also, if I buy something like Blue-shield, there’s no guarantee that it will go through for a penile prosthesis.

What’re my options other than cash?

How do I get an “out of network” doctor to work with me?

I live in Redondo Beach, Southern California. Any recommendations are welcome.

Please help me out.

- Romeo

Edit 1: Attached picture of what it says on the website.

[Time2Change]

I can only speak to your first question.

My doctor won't do the surgery unless insurance covers it. And it's for the reason driving your question. If there's a problem, such as an infection, how it's treatment is paid for becomes a clusterfuck.

Hopefully there are other guys who have Medicare and can answer your other questions.

[newbie443]

Hello Everyone,

THANK YOU

You’ve been a great source of information and encouragement to me. I’ve read EVERY thread (476 pages) in the last six months. Getting your body surgically changed forever is no easy decision to make.

But your help is always available. Random stranger: thank you so much.

I’m 38, built like a Greek God and agile. However, my penis has a brain if its own, a dead one. It won’t get up, especially when it’s required to.

I have Medicare.
It says “Medi-Cal Managed Care Health Net (DHS)”

I have FIRMLY decided to get an implant. I talked to a doctor and found out that they don’t accept Medicare as it’s “Out of Network”.

The hospital he works at/with has offered to break the money into 12 payments.

However, in case of emergency/infection , we’re not sure who pays: do I pay or do I need insurance?

Also, if I buy something like Blue-shield, there’s no guarantee that it will go through for a penile prosthesis.

What’re my options other than cash?

How do I get an “out of network” doctor to work with me?

Please help me out.

- Romeo

Welcome to the site. Good to see you have invested time to read and help yourself understand a lot and then ask better questions or answer a lot of the questions you had.

I had BCBS EPO (exclusive provider) that sounds a lot like your insurance. It only offered coverage in network and none out of network. I had a choice to go to the a low volume doctor in the less than the complete area of my home state or to self pay. The doctors I was covered for this did 2-3 implants a year and when I was sent to the business office of the largest uro group in my area I was told that many men who had the surgery with the groups doctors had the device removed as the out come was so bad. And I was told to expect to have size loss of 1-2 inches by the doctor and the man that had had surgery with one of the doctors that I spoke to. I was also advised by the business office that I would have a higher cost than insurance co-pay and deductibles. I was told insurance did not cover all the costs of the surgery. I suspect that reimbursement was so low that the doctors could not do the surgery for the low amount of reimbursement.

I would get a list of your in network doctors and research them all. If you cannot find an acceptable doctor in network then your only other option is to self pay as I did. Took me a few years to be able to self pay. Cut my bills and spending. Increased my net worth.

[passionatedoer]

Took me a few years to be able to self pay. Cut my bills and spending. Increased my net worth.

Thank you all the information. I took away a lot but thanks for mentioning that it’s not, “ signed a form and got a new penis”

It took you years to get this “dream” achieved. I’m on it too.

[warrenw]

I have Medicare.
It says “Medi-Cal Managed Care Health Net (DHS)”

I'm confused about what medical coverage you have, Medicare is not the same as Medi-Cal. Medi-Cal is California's version of Medicaid.
Traditional Medicare does cover implants and most doctors will accept it, I went to Dr Eid. I think you need to be 65 for Medicare.

You need to ask your Medi-Cal provider if they cover IPP's. If they don't, there maybe other Medi-Cal providers that will, and you can change plans during open enrollment period (not sure when that is).

Also look here: https://www.coloplastmenshealth.com/ere ... procedure/

[easymoney]

I have medicare age 69 so it was covered .. had an infection another surgery and er visits and hospital medicare covered it all for my er deductible and my daily room copay if that helps ..

[Randalltx]

Hello Everyone,

THANK YOU

You’ve been a great source of information and encouragement to me. I’ve read EVERY thread (476 pages) in the last six months. Getting your body surgically changed forever is no easy decision to make.

But your help is always available. Random stranger: thank you so much.

I’m 38, built like a Greek God and agile. However, my penis has a brain if its own, a dead one. It won’t get up, especially when it’s required to.

I have Medicare.
It says “Medi-Cal Managed Care Health Net (DHS)”

I have FIRMLY decided to get an implant. I talked to a doctor and found out that they don’t accept Medicare as it’s “Out of Network”.

The hospital he works at/with has offered to break the money into 12 payments.

However, in case of emergency/infection , we’re not sure who pays: do I pay or do I need insurance?

Also, if I buy something like Blue-shield, there’s no guarantee that it will go through for a penile prosthesis.

What’re my options other than cash?

How do I get an “out of network” doctor to work with me?

I live in Redondo Beach, Southern California. Any recommendations are welcome.

Please help me out.

- Romeo

Medicare covers the surgery throughout the United States. All Medicare plans are required to include everything Medicare includes even if you have an HMO or a PPO or something else like an advantage plan. I have the cheapest advantage plan known to man with basically zero deductibles and they covered it. My surgeon told me that Medicare covers this for anyone who has Medicare.
This is actually the perfect time to select a new insurance plan that is a new Medicare plan that will allow you to select a doctor without a referral. All you have to do is find the best doctor in your area usually it goes by county but generally speaking in your general area several counties would be covered. Ask that doctor what plans they take what Medicare plans they take I should say and then call the sales rep for the Medicare plan of your choice and tell him you want to switch to that and getting writing that they do cover the implant surgery. There's a lot of great doctors in Southern California where I used to live. I now live in Texas and I chose the doctor that was in my urology group the surgeon who does probably a safe 30-40 of these a month. They have more than one surgeon as well that does the same thing. You should have by now received your new booklet on Medicare what it covers all the plans are available in your area. Start doing your research and you'll be ready to go January

[Randalltx]

Could you please verify that you are on Medicare? Medicare is for people 65 or older or who are on disability and receiving disability payments from social security.
There are a lot of plans that sound like Medicare but more like Medicaid, or Medi-Cal,

[passionatedoer]

Could you please verify that you are on Medicare? Medicare is for people 65 or older or who are on disability and receiving disability payments from social security.
There are a lot of plans that sound like Medicare but more like Medicaid, or Medi-Cal,

Apologies. I’m very new to all this (the medical system).
A friend told me I had Medicare but seems that I’m 38 and I’ve Medical.

This is what it says.

IMG_1576.jpeg (166.5 KiB) Viewed 710 times

[Randalltx]

You probably have insurance through your employer. You can review the policy and call to verify that they cover implants in your situation. If they do not, find out when the open enrollment period is at your company as they might have options for coverage. You can then investigate and then make a decision.

If it is not through your employer, it is probably through Affordable Care Act and it should be covered as those policies are more standardized. But that is above my pay grade.

If you are on Medicaid in California, it is probably covered. Again, you would need to check.

When you are verifying coverage, take no one's word for anything. Get the proof, the codes, any restrictions.

Once you think it is covered, find your urologist who uses that plan and ask them to help you get pre-authorizied.

You have options, not the least of which is relocating or changing employers to get a plan with coverage. Good luck.