Does Medicare Cover Gender Reassignment Surgery?
- Seniors who are ready to transition may wonder, "Does Medicare cover gender reassignment surgery?" Learn Medicare's guidelines for approving this surgery.
More and more transgender Americans are seeking gender reassignment surgery so they may function biologically as their chosen gender, but the terms regulating reimbursement for the procedure vary by insurer. Because older adults who are ready to transition often receive their medical benefits through Medicare, they should understand their coverage options before proceeding.
If you're a Medicare beneficiary who's found yourself asking, "Does Medicare cover gender reassignment surgery?" the answer is maybe. That's because decisions regarding gender reassignment procedures are usually made on a case-by-case basis. If the surgery is deemed medically necessary by a Medicare-approved physician, a percentage of surgical expenses may be covered by your Medicare plan.
To understand Medicare’s rules for reimbursement, it's helpful to understand more about gender dysphoria and gender reassignment surgery.
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What Is Gender Dysphoria?
Gender dysphoria is a clinical diagnosis often given to individuals who experience distress or discomfort because their gender identity doesn’t match their sex-related physical characteristics. Although gender dysphoria is often associated with transgender or nonbinary individuals and can occur in children, teens and adults, not all gender-nonconforming or gender-diverse people experience it.
Gender dysphoria is not considered a mental health condition. However, if the resulting anxiety, depression and stress aren't treated, they may lead to serious mental health issues. The discomfort related to gender dysphoria may be addressed through psychotherapy or treatments that help align an individual's physical appearance with their gender identity. This may include gender reassignment surgery.
What Is Gender Reassignment Surgery?
Gender reassignment surgery, which is sometimes referred to as sex reassignment surgery or gender affirmation surgery, is part of the process of physically transitioning from one gender to the other. The surgery may involve more than one procedure, and it typically follows other transitional steps such as counseling and hormone replacement surgery.
Gender reassignment surgery is often broken down into top surgeries and bottom surgeries, which refer to the part of the body being transitioned. Depending on the direction of the gender transition, gender reassignment surgery may include the following procedures:
Male Transitioning to Female
- Removal of the penis, testicles and prostate gland
- Construction of a vagina and clitoris using tissue from the penis
- Construction of a labia using scrotal tissue
- Shortening of the urethra
- Facial feminization
- Voice change surgery
- Hair reconstruction
- Adam’s apple reduction
Female Transitioning to Male
- Removal of the breasts, ovaries and uterus
- Closing of the vagina
- Creation of a penis and scrotum using available tissue
- Penile implants
- Lengthening of the urethra
- Voice change surgery
Is Gender Reassignment Surgery Medically Necessary?
Gender reassignment surgery may be considered medically necessary to treat anxiety and depression related to body dysphoria. Health plans such as Medicare may make a decision on the medical necessity of gender reassignment surgery based in part on criteria such as an individual’s history of hormone therapy, mental health counseling and recommendations from professionals in the field.
Does Medicare Cover Gender Reassignment Surgery?
Medicare covers the costs of gender reassignment surgery if it’s considered medically necessary. Surgery may be deemed medical necessary to treat mental health issues related to a gender dysphoria diagnosis or simply because an individual demonstrates a committed desire to transition.
Medicare may have additional requirements before approving reimbursement for this surgery, including:
- Extended participation in mental health counseling
- A recommendation from two or more mental health professionals
- Completion of hormone therapy for a year or more
- Living as the identified gender for a significant amount of time
Decisions are made on a case-by-case basis. If surgery is approved, your plan’s standard copays, coinsurance and deductibles apply.
Does Coverage for Gender Reassignment Surgery Vary by State?
Although Medicare is a federally regulated program, state laws may impact Medicare's decision to cover gender reassignment surgery. Information on state health care laws and policies that may affect coverage for transgender-related medical care can be found by visiting the Movement Advancement Project.
What Is Hormone Therapy?
Hormone therapy is a medical treatment that adjusts an individual's hormone levels so they align with their gender identity. Individuals who wish to undergo gender reassignment surgery must typically undergo hormone therapy for a year or more prior in order to be approved for the procedure.
Does Medicare Cover Hormone Therapy?
Medicare covers the cost of hormone therapy through its Part D prescription drug plan or any Medicare Advantage plan that bundles in prescription drug coverage. The therapy must be deemed medically necessary.
What Is Facial Feminization Surgery?
Facial feminization surgery (FSS) is a component of gender reassignment. This procedure alters a person’s facial features so they appear more feminine. This surgery may be performed on all, or any combination of, the following features:
Does Medicare Cover FFS?
Because most insurers consider facial feminization surgery to be an elective cosmetic procedure, it’s not typically covered by Medicare plans.
What Other Components of Gender Reassignment Surgery Aren’t Covered by Medicare?
Medicare doesn’t currently cover hair removal, vocal cord surgery and any aspects of the transition that are considered purely cosmetic.
What Happens If Medicare Doesn’t Approve Your Surgery?
If coverage for surgery is denied, you have the right to appeal the decision. Guidelines for appeals should be included in your plan terms, but you may typically start with the following steps:
- Original Medicare: Start by filling out a Redetermination Request Form. Medicare typically returns a decision within 60 days.
- Medicare Advantage: Submit an appeal in writing to your insurance provider. A decision should be returned within 30 to 60 days.
Be sure to include relevant documentation from health care providers and keep copies of everything you submit. If your appeal is denied, you may escalate it to the next level. It may be helpful to consult with a lawyer who specializes in Medicare or transgender rights before filing upper-level appeals. Medicare allows up to four appeals before the denial becomes final.
Where Can You Find Help?
If you need help understanding your benefits, appealing a denial of services or dealing with discrimination, you can get assistance in one of the following ways:
- Contact Medicare: If you need help handling a claim or understanding your benefits, you may call Medicare directly at 1-800-MEDICARE. You can also get assistance 24 hours a day by chatting with a representative online.
- Consult a Lawyer: If you’ve been denied coverage for gender reassignment surgery, it may be helpful to consult a lawyer who specializes in Medicare or transgender rights. To find a lawyer near you, visit the Trans Legal Services Network Directory.
Transgender Advocacy Organizations: The Affordable Care Act makes it illegal for most medical professionals to discriminate against you for being transgender. If you’ve encountered discrimination or harassment, you may seek help through a transgender advocacy organization such as the National Center for Transgender Equality.