Gender Affirmation: Does Medicare Cover It?

Medicare covers medically necessary services, meaning any standard services needed to diagnose or treat medical conditions. While Medicare hasn’t always considered affirmation services medically necessary, two important changes were announced in recent years.

In 2014, the Medicare Appeals Board lifted an exclusion on affirmation-related medical care that had classified services like gender affirmation as “experimental.” The decision to lift the ban was supported by research findings that affirmation-related services are medically necessary for transgender people who wish to undergo them.

In 2016, the Centers for Medicare & Medicaid Services (CMS) announced that it would not be issuing a national coverage determination for gender affirmation surgery. Instead, gender affirmation surgery is covered if it’s deemed medically necessary by local Medicare Administrative Contractors (MACs) and Medicare Advantage plans on a case-by-case basis.

Since gender affirmation surgery and most related services are considered medically necessary for individuals who wish to physically transition, Medicare will cover most of the services related to gender affirmation.

Medicare should cover hormone therapy, gender affirmation surgery, and counseling if your doctor classifies it as medically necessary for your situation.

Hormone therapy

Hormone therapy can be administered during the transition from male to female (MTF) or nonbinary (MTN) and from female to male (FTM) or nonbinary (FTN). Hormone therapy commonly includes:

• Estrogen therapy. This is used when people are transitioning from MTF or MTN. Estrogen administration helps to induce feminizing characteristics and is often paired with antiandrogens to suppress masculine features.
• Testosterone therapy. This is used when people are transitioning from FTM or FTN. Testosterone helps to suppress feminizing characteristics and induce masculine features.

While not every transgender individual chooses to undergo hormone therapy, it can be considered medically necessary for people who wish to physically transition.

Gender affirmation surgeries

Gender affirmation surgery is a group of surgical procedures that allow trans people to transition their physical appearance so that it better represents their gender identity.

Many types of gender affirmation surgeries exist; they’re commonly divided into “top surgeries” and “bottom surgeries,” depending on the area of the body. Here are more details:

• Top surgeries. There are multiple types of top surgeries, depending on your desired results. For FTM or FTN, top surgery involves removing breast tissue and flattening the chest. For MTF or MTN, it involves using breast augmentation to increase the size of the breasts.
• Bottom surgeries. There are also multiple types of bottom surgeries available for individuals who wish to change their genital appearance. For FTM or FTN, phalloplasty and metoidioplasty are surgeries used to construct a neopenis. Scrotoplasty and testicular implants may also be used to construct a scrotum. For MTF or MTN, vaginoplasty and penile inversion techniques are used to construct a sensate vagina.

Medicare covers all the surgeries listed above (and more) when medically necessary, except for breast augmentation for MTF or MTN individuals. This is because breast augmentation is generally considered a cosmetic procedure.

Additional procedures, such as laser hair removal, tracheal shave surgery, and facial feminization surgery, may also be performed as part of your gender affirmation. But these surgeries are generally considered cosmetic in nature, so Medicare doesn’t cover them.

Counseling

Gender dysphoria is the conflict an individual feels between their gender identity and the sex assigned to them at birth. Trans people with gender dysphoria might consider treatment options like counseling, hormone therapy, and gender affirmation surgeries.

Medicare covers both inpatient and intensive outpatient mental health therapy. Medicare will also cover therapy for transgender individuals who have already undergone affirmation surgery and need additional support.

It can sometimes be difficult to determine whether Medicare will cover a service or not. Coverage decisions for Medicare plans are generally governed by the following factors:

• Federal laws. These laws determine what benefits insurance companies offer and who’s licensed to provide these services in your state.
• National coverage laws. These decisions are made by Medicare directly and determine what is and isn’t covered.
• Local coverage laws. These decisions are made by companies and determine whether something is medically necessary or not under Medicare.

The best way to determine if your gender affirmation procedure is covered by your Medicare plan is to speak with your doctor directly.

If Medicare denies your request for coverage for gender affirmation and you and your doctor believe it to be medically necessary, you can appeal Medicare’s decision.

• For original Medicare (parts A and B) beneficiaries, you can fill out a Redetermination Request Form to appeal. Medicare then has 60 calendar days to make a decision on your appeal.
• For Medicare Advantage plans, you must go directly through your plan provider to appeal. Your Medicare Advantage plan then has 30 to 60 calendar days to respond to your appeal.

If you disagree with the decision made after your first appeal, you can appeal up to four more times before a final decision is made.

Medicare consists of different parts and plans that cover your various medical needs, from hospital and medical insurance to prescription drug coverage. Different affirmation-related services are covered under different Medicare parts.

Part A

If you are hospitalized for a gender affirmation surgery, you will be covered under Medicare Part A. This coverage also extends to other services you might need while hospitalized, such as nursing care, physical therapy, and certain medications.

Part B

Most of the remaining services connected with affirmation-related procedures are covered under Medicare Part B. These services include preventive, diagnostic, and post-operative doctor’s office visits, laboratory testing for hormones, and mental health services.

Part C (Medicare Advantage)

If you’re enrolled in a Medicare Advantage (Part C) plan, any services that would be covered under Medicare parts A and B are covered under your plan. In addition, most Advantage plans also cover prescription drugs that may be used for hormone therapy.

Part D

Any medications prescribed for gender affirmation or affirmation-related services, like hormone therapy, should be covered by Medicare Part D or Medicare Advantage prescription drug plans.

The determination of this coverage is dependent on the specific plan you are enrolled in.

Medicare supplement (Medigap)

A Medigap plan that covers the costs associated with your deductibles, coinsurance, and copayments can help keep out-of-pocket costs low for your affirmation-related services.

Without insurance, the cost of gender affirmation surgeries depends on the type of surgery performed. For example:

• Top surgeries can cost anywhere from $3,000 to $11,000.
• Bottom surgeries can cost anywhere from $4,000 to $22,000.

Even if Medicare covers these surgeries, you’ll still have out-of-pocket costs. These costs include:

• Part A costs: a premium of up to $458 per month, a deductible of $1,408 per benefits period, and a coinsurance of $0 to more than $704 per day, depending on the length of your hospital stay
• Part B costs: a premium of at least $144.60 per month, a deductible of $198 per year, and a coinsurance of 20 percent of the Medicare-approved amount for your services
• Part C costs: all the costs associated with parts A and B, plus an additional plan premium, drug plan premium, copayments, and coinsurance
• Part D costs: a variable premium depending on your plan, a deductible of $435 in 2020, and a variable copayment or coinsurance for your medications depending on your plan’s formulary

One important note: If you’re enrolled in a Medicare Advantage (Part C) plan that uses in-network providers only, such as a Health Maintenance Organization (HMO) plan, your affirmation-related services will only be covered if the providers you choose are in your plan’s network.

• In recent years, the law has changed to allow the coverage of affirmation-related services for transgender Medicare beneficiaries.
• If your gender affirmation procedures are deemed medically necessary, Medicare will cover them.
• Any decisions related to the noncoverage of these services or procedures can be handled through an appeals process with Medicare or your plan directly.
• Even if your plan covers your affirmation-related services, you may still have out-of-pocket costs associated with your care.
• For more information on which gender affirmation procedures your Medicare plan covers, consult with your doctor.