It ultimately depends on your healthcare plan, the surgery you’re inquiring about, and why you’re getting it done.
The United States government offers six different healthcare plans:
- State Children’s Health Insurance Program (SCHIP)
- Department of Defense TRICARE and TRICARE for Life programs (DOD TRICARE)
- Veterans Health Administration (VHA) program
- Indian Health Service (IHS) program
Together, these programs provide healthcare coverage for about one-third of people in the United States. (The other two-thirds get it from private insurers).
Most people with a government healthcare plan have Medicare. Medicaid, for example, is only for people under a certain income bracket, while the VHA program is only for veterans.
So, does Medicare cover the cost of gender affirming surgeries in 2023? It should. To understand instances when it may not, you need to understand how Medicare works.
Terms to know
Premium: This is the fixed dollar amount you pay each month to be enrolled in a healthcare plan.
Deductible: This is the amount you must contribute out of pocket to your healthcare each year before your insurer will start to kick in money.
Copayment: This is the fixed dollar amount you pay anytime you receive treatment.
Coinsurance: This is the percentage of the treatment cost that you must pay anytime you receive treatment. This dollar amount varies based on cost.
Medicare covers all ”medically necessary” services and surgeries, as well as preventive services.
So, if the gender affirming surgery you want is deemed medically necessary or as a type of preventive care, your plan should pay some portion of the overall cost.
First, your clinician will determine if a type of care is medically necessary. If it is, they’ll provide a letter of medical necessity to your health plan as part of a certification or utilization review process.
Next, your local Medicare administrative contractors (MACs) will review the material, and determine whether it will be covered by your Medicare plan. The decision they make will be affected by your local coverage laws.
If the MACs determine that it’s *not* medically necessary, you can appeal the decision. You can learn more about the appeal process.
The plans are broadly categorized as the following:
- Original Medicare (Part A and B)
- Medicare Advantage Plan (Part C)
- Medicare Supplemental Insurance (Part D)
Most people with Part A don’t have to pay a monthly premium. But if you don’t qualify for premium-free Part A, you may have to buy it. It will cost $278 or $506 each month, depending on your eligibility.
In either case, you’re responsible for a $1,600 deductible for *each* inpatient hospital stay before Medicare starts to pay. You’ll have to pay this amount for every hospital stay in a given benefit year.
You don’t have to make additional payments toward your inpatient hospital stay unless you’re there for more than 60 days:
- Days 61-90: $400 copayment each day
- Days 91-150: $800 copayment each day
- After day 150: You pay all costs.
The standard premium for Part B in 2023 is $164.90 each month. If your annual income in 2021 was more than $97,000, your premium in 2023 will be higher.
You’re responsible for a one-time $226 deductible before Medicare starts to pay. After you pay the deductible, you’ll usually pay 20% of the cost for each Medicare-covered service. Medicare typically pays for the remaining 80%.
If you receive outpatient hospital care, you may also have to pay a copayment to the hospital for each service. Your copayment usually will not exceed the Part A hospital stay deductible amount ($1,600).
To enroll in a Part C plan, you must first enroll in a Part B plan and pay a monthly premium for Part B.
Certain Part C plans will pay some or all of your Part B premium. This is known as a Medicare Part B premium reduction.
Your Part C premium, deductible, copayment, and coinsurance amounts depend on the company providing the plan.
Your Part D premium, deductible, copayment, and coinsurance amounts depend on the company providing the plan. If your annual income in 2021 was more than $97,000, your premium in 2023 will be higher.
These costs can add up quickly. So, if your jaw is dropping at these numbers, note that Medicare has a program called Extra Help that can help you pay your premiums, annual deductibles, and copayments for prescription drugs.
There are also financial assistance programs outside of Medicare you can apply to for additional coverage, says Casey Tanner, MA, LCPC, queer-affirming sex therapist and founder of The Expansive Group.
Some of these include:
- The Jim Collins Foundation
- Genderbands Transition Grants
- Black Transmen, Inc. Surgery Scholarship
- Point of Pride
“Many folks pursuing gender-affirming surgery have successfully used crowdfund resources like GoFundMe to ask for support from friends, family, and social media,” they add.
The Health Insurance Marketplace offers insurance for those who are uninsured or who have inadequate insurance coverage (aka ”underinsured”).
Marketplace coverage and costs vary state to state and plan to plan. Marketplace plans generally cover surgeries and preventive services deemed medically necessary.
“Most Marketplace plans should offer some amount of transition-related care,” says Jack Bartel, PsyD, queer-affirming clinical psychologist with Choosing Therapy. “But these plans are not devoid of pesky hoops transgender individuals may have to navigate to get care.”
Many plans require pre-authorizations or therapy for medical interventions to be covered, which can be frustrating, costly, and difficult to navigate, he explains.
So, before you pick a plan, you’d be wise to take a closer look. In particular, hold up a magnifying glass to the “Evidence of Coverage” and “Certificate of Coverage” sections, Bartel suggests. Here, you’ll find info about procedures and services that are covered (or excluded) under each plan.
If you can, you want to avoid plans that use the following phrases and sentences:
- “All procedures related to being transgender are not covered.”
- “gender change”
- “gender identity disorder”
- “gender identity dysphoria”
These phrases are usually only present when gender affirming surgeries are *not* covered.
If you have general questions about gender affirming surgeries and care, Tanner recommends taking a moment to scroll through the Human Rights Campaign fact page. You can also watch their in-depth Q&A on YouTube.
“Finding a trans-knowledgeable therapist or case worker can also be a helpful place to start, as they’re often knowledgeable about medical referrals in their area,” they add.
If you have specific questions about finding insurance coverage for gender affirming surgery, you may find these online resources helpful:
- The Transgender Legal Defense & Education Fund
- National Center for Transgender Equality
- Medicare FAQ
- Kaiser Family Foundation
You can also call Medicare directly at 1-800-MEDICARE or 1-800-633-4227. This line will connect you to a real person, 24 hours a day, 7 days a week, excluding some federal holidays.
Similarly, you can reach the Healthcare Marketplace at 1-800-318-2596.
Gabrielle Kassel (she/her) is a queer sex educator and wellness journalist who is committed to helping people feel the best they can in their bodies. In addition to Healthline, her work has appeared in publications such as Shape, Cosmopolitan, Well+Good, Health, Self, Women’s Health, Greatist, and more! In her free time, Gabrielle can be found coaching CrossFit, reviewing pleasure products, hiking with her border collie, or recording episodes of the podcast she co-hosts called Bad In Bed. Follow her on Instagram @Gabriellekassel.