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

Medicare for transgender-related health care

By Home Media

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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

  • You have lived for at least 12 months as the gender role you’re transitioning to

  • You are free of serious medical or mental health issues or are receiving sufficient medical care to control those issues

  • You need two recommendations from mental health providers

If you meet those requirements, your doctors can submit your case for Medicare coverage, and you’ll likely get assistance with your transition costs as long as your doctors participate in Medicare. However, you’ll still be responsible for Medicare deductible and coinsurance.

If you have a Medicare Advantage plan , your health-care provider will likely have to submit your case to the insurance company for prior authorization before you can get coverage for procedures or hormone therapy.

However, not all health-care providers accept Medicare , so make sure you double-check with your doctor to find out if your procedure is covered.

RELATED: Find out if there are Medicare Advantage plans in your area.

Does Medicare cover hormone therapy?

If you are prescribed hormone therapy, Medicare Part B will pay for your lab work and doctor visits to monitor your response to the hormones. However, Original Medicare doesn’t cover the cost of the hormones. You’ll have to pay for them out of pocket, or you can enroll in a prescription drug plan, also known as Medicare Part D , at an additional cost to get coverage for hormone therapy.

Does Medicare cover transgender surgery?

Gender-affirming surgery, also known as gender confirmation surgery , is a term that refers to a series of procedures a transgender person may undergo to achieve the physical appearance that fits their identity.

Medicare covers medically necessary transgender treatments, including gender-affirmation surgery, on a case-by-case basis. If approved, Medicare Part B — medical insurance — will pay for your doctor visits and approved surgery. Medicare Part A — hospital insurance — covers inpatient care.

What’s the difference between medically necessary and cosmetic procedures?

As a transgender person, gender-affirming surgeries can have a significant effect on your well-being. However, not all procedures are covered by Medicare. To qualify for Medicare coverage, procedures must be classified by the insurance company as “medically necessary” rather than “cosmetic.”

Coverage for transgender procedures is typically limited to those that change primary sex characteristics, including:

  • For people assigned female at birth and transitioning: Removal of breasts, ovaries, and uterus, and genital reconstruction

  • For people assigned male at birth and transitioning: Removal of the penis, testicles, and prostate gland and genital reconstruction

While trans individuals often undergo other procedures to make their appearance match their gender identity, such as facial contouring or hair transplants, Medicare designates these procedures as cosmetic and does not cover them.

RELATED: Speak with a licensed Medicare insurance agent by calling: 844-259-6504 .

What to do if you’re denied coverage

If your request for health-care services or procedures is denied, you have the option of appealing that insurance company’s decision and requesting a redetermination.

If you have Original Medicare, complete the Redetermination Request Form and send it to the company that handles your Medicare benefits. In the request, include your name, address, and Medicare number. Circle the items you disagree with and include a written explanation of why you think the items should be covered. Include any supporting documentation, such as medical records or statements from your doctor.

If you are on a Medicare Advantage plan , you typically have 60 days after receiving a denial to file an appeal. While some plans allow you to appeal over the phone, others require you to appeal in writing, so make sure you check your insurance company’s policies.

If you’d like to consult a licensed Medicare professional before selecting the Medicare coverage that’s right for you, call 844-259-6504 and ask about Medicare for transgender-related health care .

Kat Tretina is a journalist and copywriter for Home Media with expertise in personal health and personal finance. Her content has been featured on sites such as Everyday Health, HuffPost, Forbes, Investopedia, and Credit Karma. Kat calls Orlando, Florida home.

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