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

Medicare for transgender-related health care

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By Home Media

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  • 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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