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Feb. 8, 2021, 4:21 p.m. EST

Medicare for transgender-related health care

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What you should know:

  • 1.4 million adults in the United States identify as transgender

  • Hormone therapy typically costs $100 per month

  • Gender affirmation surgery usually costs between $7,000 and $50,000

  • There are approximately 10,000 transgender Medicare beneficiaries

  • Medicare covers medically necessary transgender surgery on a case-by-case basis

  • Those insured through Medicare are more likely to get transition-related surgery than those with private insurance

Over 1.4 million adults in the United States identify as transgender. Gender-affirming surgeries and hormone therapy can be an essential part of a trans person’s transition, but those procedures can be costly, and many private insurance plans don’t cover them.

For the relatively small number that qualifies for Medicare coverage — just 0.7% of transgender people are Medicare beneficiaries — Medicare can provide significant relief. Medicare ensures that medically necessary care is covered, including some gender confirmation procedures .

How much do surgery and hormone therapy cost?

Many trans people opt to undergo forms of medical transition so their appearance better aligns with their gender identity. Some — but not all — decide to get gender-affirmation surgery, including procedures like breast removal or augmentation and genital reconstruction.

For those who utilize hormones, the cost is typically $100 per month, and support during this time through therapy is approximately $100 per session.

Trans people who want gender-affirmation surgery need a substantial amount of money to cover the expense. Depending on the procedures they need, gender-affirmation surgery can cost between $7,000 and $50,000 , but some procedures — such as phalloplasties —  cost even more.

Medicare transgender coverage

For decades, Medicare specifically excluded transgender surgery and related procedures. Anyone attempting to get Medicare transgender coverage was denied because the procedures were deemed “experimental.”

In 2014, the Centers for Medicare & Medicaid Services issued a new determination that removed the existing exclusion for transgender surgery . Now, Medicare will determine coverage of transgender-related procedures on a case-by-case basis .

In addition, Medicare must cover routine preventative care if it’s clinically necessary, regardless of the gender marker on your Social Security records. If there is a potential for gender mismatches between your records and gender identity, the physician or hospital should use billing code (condition code 45) to help process your claims.

To qualify for Medicare coverage for treatment, you must meet the following criteria:

  • You have been diagnosed with gender dysphoria, previously known as gender identity disorder

  • You have completed at least 12 months of continuous hormone therapy

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