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December 4, 2014 10:58 PM   Subscribe

Help me move to Vermont and acquire a vagina. (This is not a joke.) Insurance and relocation-related questions within.

Two facts have recently come to my attention:
  • If I do not get gender reassignment surgery pretty soon I am going to lose my goddamn mind.
  • The state of Vermont requires Obamacare plans to cover GRS.
I am a few days away from finishing grad school, and I'd been planning to move to somewhere in the northeast soon anyway. Originally I'd had my eye on Boston, where my wife and I have various friends and family. But it looks like the quickest route to surgery and sanity might be to shift my sights to Vermont, at least for a year or so.

Here are some things I'd like to know:
  • I have no actual idea how this insurance exchange business works. The Vermont exchange website says open enrollment lasts until February 15. What do I need to do by then to become eligible to enroll in a plan there? (Have an address in VT? Have lived there for a certain length of time? Have a job there?)
  • What is Vermont like as a place to live? What should I know about it if I'm considering moving there? What do you wish you'd known before you moved there?
  • More specifically: where in the state might it be most pleasant to be an overeducated 30something queer? Where might I find like-minded roommates or some sort of community?
  • What are the major industries or employers there? Where (besides Craigslist or Indeed) should I be looking for jobs?
  • Alternately: any ideas for jobs there that might make an interesting temporary adventure for someone taking a yearlong post-grad-school detour and trying to figure out what comes next?
  • Is this whole thing completely moronic? What haven't I thought of that I should be?
posted by nebulawindphone to Grab Bag (13 answers total) 15 users marked this as a favorite
 
Something you should think of before going further (if you haven't yet) is what surgeon(s) you'd want to use and if they are in-network for any of Vermont's available Obamacare plans (or take insurance in general.) I have heard about this as an issue specifically with GRS (although not specifically in Vermont)--insurance plans covering it but there being no or very few in-network surgeons qualified and experienced enough to do it.
posted by needs more cowbell at 11:18 PM on December 4, 2014 [1 favorite]


(You're right that not many surgeons who do this take insurance. I'm hoping to go to Bowers, who does take insurance, and whose office staff has a pretty good reputation for actually doing the legwork to get insurance preauthorization. But yeah, the in-network thing is a good point, and something I'll need to look into.)
posted by nebulawindphone at 11:25 PM on December 4, 2014


Vermont is awesome. It is so awesome in fact that there aren't a ton of jobs. Burlington is the biggest city and has a few large employers. Other medium sized cities have some other options. Are you and wife in occupations that are more easily employed?
posted by k8t at 1:20 AM on December 5, 2014 [1 favorite]


The other big pitfall around trans-inclusive coverage aside from surgeons is the cap on dollar amount of coverage. Plans that want to say they're trans-inclusive (or are required to be) without actually covering surgery will have a low annual or lifetime cap on transition-related care. "Low" means in the vicinity of $25,000, which is nowhere near sufficient to cover surgery plus a multi-day hospital stay. If you can find someone who has had surgery with Bowers covered by insurance, they can figure out how much was billed to insurance by looking at their Explanations of Benefits.

In other words, when shopping for trans-inclusive insurance, you need access to the full details of the plan (i.e. exclusions, coverage limits and ideally coverage criteria for GRS) that aren't always readily available. In Minnesota, there was an effort to figure out what plans on the exchange covered what, but it was tricky. I really don't know much about the trans community in Vermont, but Outright might have figured this out (they do do work on trans stuff) or they might know who the right trans-specific organisation to talk to is (if there is one--I'm not sure there is).

There just aren't a lot of jobs in Vermont. That's the biggest hole in this plan aside from the lack of information available about insurance. (Disclaimer: I did the post-grad school job hunt thing last year and I was keeping an eye out for a job in Vermont and found nothing to apply to. My "near my mother" cities were Boston and Montreal. However, I was on the hunt for a job at least semi-related to my degree, rather than any job on offer, so I may be particularly down on the Vermont job situation. ) If you're days away from a PhD, there are a couple of colleges in Burlington, so you might be able to string together adjunct positions. Or if your degree is in a subject where "go work in someone's lab" is an option, UVM might have some possibilities. The same goes for living in Vermont and trying to work in Hanover, NH, I guess. (I have no idea how many jobs are in Hanover/Lebanon that aren't somehow related to academia, but I do know it's big enough to have big box stores.)

You may want to reframe the search for a place as "Where are there resources that can get me insurance?" rather than "Vermont requires coverage, so I've got to go there". Compass in Boston presumably knows what coverage is like on the exchange, MTHC should know for Minnesota. The big name clinics (Howard Brown, Callen-Lorde, Whitman-Walker, Tom Waddell, Lyon-Martin) probably have some idea what insurance options are available on the exchanges where they are. (I think Tom Waddell ought to know for California. There used to be a city of San Francisco health plan that people had to move off of when the exchanges opened.)
posted by hoyland at 5:26 AM on December 5, 2014 [4 favorites]


Yeah, keep in mind that Vermont is tiny; the population of the entire state is about 625,000, or about the size of a city like Wichita. The major employers (beyond the usual sorts of service jobs) are tourism, insurance, and agriculture; there's not a huge demand for highly educated folks like yourself.
posted by Johnny Assay at 5:31 AM on December 5, 2014


Well so, it seems like there are two separate problems here. 1) You need gender confirming surgery and 2) You might need to move to Vermont to get it, and moving to Vermont is complicated (it's rural in many places, it's kind of liberal paradise, but you don't yet have a job or a job you can port). To take those apart:

Is Vermont your only option? It wouldn't surprise me, exactly, but you should ask yourself that and really try to come to terms with your options. How good of an option is it? Medicaid can suck sometimes about things like pain control (e.g. Washington state only lets doctors give Medicaid patients methadone for pain control - it kills people and it doesn't help pain very much -- I think this plays out in denying some forms of estradiol that are safer with trans health care). Do you have to go through psychiatrist after psychiatrist to get approval, which isn't guaranteed? Maybe it would be better to get a job with a private insurer who covers gender confirming surgery some place else in the US (I know the City of Portland, OR does). I know from hard knocks that government programs that seem revolutionary and wonderful are often difficult to access or offered for a limited time only. I'd never relocate for one now.

My family did something more drastic and it way didn't work out for my family members. They uprooted their lives in despair because their treatment was stalled, only to find that the specialist they'd hung their hopes on declined to take their case once they were actually there. The guy was technically in their PPO network, well reviewed and taking patients. It just wasn't a good fit. Like gender confirming surgery, it was rare and there wasn't another guy down the block - in fact, they'd have done better to stay in an urban area. They had three quit jobs, most of their support network hundreds of miles away, their house sold for nothing, even a pet given up. It was hard to watch. I encourage you to assess the risks of uprooting. As you know, you're going to need a lot of support. Both the lucre and the social capital to move might be more wisely spent squirreling away money for the surgery yourself - or training for a job that will give you trans health care benefits. Shit, a bunch of colleges offer gender confirmation surgery as a benefit! And more will likely follow, given that Medicare will pay now.

However, if you want to move to Vermont for the whole package, I'd suggest giving Flex Jobs a gander. It's worth the yearly fifty bucks - they vet telecommuting jobs from legit (often Fortune 500) companies. There's everything from want ads for database administrators to Apple phone support. Their blog is a goldmine for how to find telecommuting jobs not advertised. Many they post even offer full time benefits. I use them. Best of luck to you - this is one area where the tide seems to be turning. You don't need to bolt in the night - I think you can bloom where you're planted if you want to stay. I am an insurance navigator if you'd like to memail me.
posted by sweltering at 5:42 AM on December 5, 2014 [5 favorites]


I lived in Vermont only briefly, but lived a long time next door in both New Hampshire and Massachusetts. A lot of people live in Vermont but commute to jobs in NH and MA - for instance, Dartmouth College and its medical school are huge employers in the Upper Valley; and when I lived in Northampton (MA), I knew a couple of people who lived in Brattleboro but worked in Amherst. New England: teeny and terrific. Good luck!
posted by rtha at 5:52 AM on December 5, 2014 [3 favorites]


I don't know anything about Vermont, but I do know a few people who have traveled overseas for GRS and been very happy with the whole experience. Have you considered that option and crunched the numbers in terms of overall cost?
posted by Faint of Butt at 6:25 AM on December 5, 2014


Moving to a new state (any new state) counts as a qualifying life event, which generally means you can enroll in a new insurance plan even outside the open-enrollment period. So I understand the push in terms of your own mental and physical health, but if you're going to change states, you most likely don't have to let the open-enrollment deadline be a factor.
posted by jaguar at 6:41 AM on December 5, 2014 [2 favorites]


Take out a spreadsheet and compare your out-of-pocket costs for moving to (e.g.) San Francisco, geting a $100K/year job, paying $15-20K in excellent PPO health insurance (maximum) and getting the majority fo the surgery covered, vs. moving to Vermont, making less money, and possibly having HMO health insurance that doesn't cover your surgery entirely or at all. You might do well to just buy health insurance or move somewhere with a good PPO plan through your job.

And/or, call Dr. Bowers and have her staff talk you through the insurance coverage from different providers. Her office would have the greatest experience and you could resolve it quickly by phone.
posted by htid at 9:04 AM on December 5, 2014


Massachusetts and California also include GRS under MedicAid plans, so you have some more options than Vermont.
posted by klangklangston at 6:57 PM on December 5, 2014


Update: as of today, insurers in NY have been instructed to cover GRS. According to someone I spoke with at Gay and Lesbian Advocates and Defenders, there are similar laws or policies in Massachusetts and Connecticut.

The person I spoke to at GLAD also gave me more information about the scope of these laws: in addition to plans purchased on the exchange in these states, the laws cover ordinary employer-provided health plans (but not "self-insured" plans where the employer assumes the risk itself) for companies with headquarters in VT, NY, MA or CT (but not necessarily for jobs in those states with employers headquartered elsewhere). In MA and VT (and possibly now also NY?) Medicaid is also required to cover GRS, but reportedly there are very few

I've only been looking into the situation in the northeast, since I've got personal reasons for wanting to move there, but apparently as of right now there are similar laws or policies in effect in California, Oregon, Washington, Colorado, Illinois and D.C. I haven't done any research on the details there.
posted by nebulawindphone at 9:14 AM on December 11, 2014 [1 favorite]


Further update: I moved to Boston. Word from the trans women I know here is that many (or all?) plans available on the exchange in MA treat out-of-state providers as automatically out-of-network — and there are no surgeons performing SRS in MA. However, at least some employer-provided plans (e.g. BCBS MA's PPO plan) appear to cover out-of-state procedures and have Bowers listed as in-network.
posted by nebulawindphone at 12:41 PM on July 18, 2015


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