Medicare also covers medically necessary hormone therapy for transgender people. These medications are part of Medicare Part D
Medicare Part D
Medicare Part D, also called the Medicare prescription drug benefit, is an optional United States federal-government program to help Medicare beneficiaries pay for self-administered prescription drugs through prescription drug insurance premiums. Part D was originally propo…
Does Medicare cover transgender care for transgender people?
Private Medicare (Medicare Advantage, Medicare Cost Plus or Medicare Part D, etc.) These plans should also cover routine preventive care and transition-related care for transgender people, however, the Medicare override “condition code 45” cannot be used for private Medicare Advantage plans.
Does Medicare cover gender reassignment surgery?
Procedures covered by Medicare may include hormone therapy, gender affirmation surgeries, and counseling before and after surgery. Gender affirmation or confirmation, formerly called gender reassignment, is a surgical procedure or series of procedures that transgender people may use to help affirm their gender identity.
Can I get Medicare coverage for transition-related prescription drugs?
For prescription medications that are transition-related, we recommend you request a “coverage determination” from your Medicare Part D or Medicare Advantage plan. You can find more information on this guide and access a model coverage determination form. What Do I Do if Coverage is Denied?
Can health insurance companies discriminate against transgender people?
Under the ACA, it is illegal for most insurance companies to have exclusions of transition-related care, and it is illegal for most health providers to discriminate against transgender people, like by turning someone away or refusing to treat them according to their gender identity.
Does insurance cover hormone therapy for 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.
How much does transgender medication cost?
The prescriptions and regular check-ups involved can cost around $1,500 a year. For transgender men's hormone therapies, testosterone injections typically cost around $80 monthly, with testosterone patches costing more than $300 monthly.
Does Medicare pay for gender reassignment surgery?
Medicare provides coverage for gender reassignment surgery, although it needs to be deemed as medically necessary. A person can appeal the decision if surgery is denied.
What modifier is used for transgender?
modifier KXSummary: Use modifier KX (requirements specified in the medical policy have been met) and Condition Code 45 (Ambiguous Gender Category) on claims for services for transgender, ambiguous gender, or hermaphrodite patients.
How much does estradiol cost without insurance?
This is a generic drug. The average cost for 30 Tablet(s), 1mg each of the generic (estradiol) is $22.09. You can buy estradiol at the discounted price of $5.49 by using the WebMDRx coupon, a savings of 75%.
How much does testosterone injections cost with insurance?
The good news is TRT doesn't have to be expensive. In fact, most insurance companies cover all forms of testosterone replacement therapy, which means you'll only need to cover the co-pay. Co-pays can range anywhere from $30-$100 per month, depending on your location, treatment protocol and insurance plan.
Is facial feminization surgery covered by Medicare?
Medicare does not cover certain cosmetic surgery procedures, such as laser hair removal and facial feminization surgery, because these are not considered medically necessary.
Is Top surgery considered medically necessary?
Not every person with gender dysphoria has the need to undergo surgery, but for those who do, Top Surgery is medically necessary and has been scientifically proven to be effective at treating gender dysphoria and improving quality of life, in both adults and minors.
Is there a diagnosis code for transgender?
0, code F64. 0 covers both “gender identity disorder in adolescence and adulthood” and “gender dysphoria in adolescents and adults.”
What is the ICD-10 code for transgender male to female?
ICD-10 notes that new code F64. 0 covers both “Gender identity disorder in adolescence and adulthood” and “Gender dysphoria in adolescents and adults.” And for revised code F64. 1, ICD-10 instructs you to “Use additional code to identify sex reassignment status (Z87. 890).”
How do you code transgender?
ICD-10-CM Coding Tied to Gender Transition Use code Z87. 890 Personal history of sex reassignment for sex reassignment surgery (SRS) status.
Medicare Part D Plans May Cover Hormone Therapy Medications
The types of hormone therapy medications that may be covered by a Medicare Part D prescription drug plan may vary from one plan to the next.
Medicare May Cover Gender Reassignment Surgery in Some Cases
In 2014, Medicare lifted exclusions for gender reassignment surgery under Medicare Part A.
Medigap Plans Can Help Cover Gender Affirmation Surgery Medicare Costs
If your gender reassignment surgery is covered by Medicare, a Medicare Supplement Insurance plan can help pay for some of your out-of-pocket Medicare costs like deductibles and copays.
What Does Medicare Cover For Transgender People
Medicare covers routine preventive care regardless of gender markers. Medicare covers routine preventive care, including mammograms, pelvic and prostate exams. Medicare has to cover this type of care regardless of the gender marker in your Social Security records, as long as the care is clinically necessary for you.
What If I Need Hormone Therapy
For pubertal suppressants: You must reach puberty level of Tanner Stage II which is determined by your doctor.
What Laws Protect Me
The Health Care Rights Law, as part of the Affordable Care Act prohibits sex discrimination, including anti-transgender discrimination, by most health providers and insurance companies, as well as discrimination based on race, national origin, age, and disability.
Alaska Medicaid Must Cover Gender
Starting this month, Alaska Medicaid can no longer deny coverage to transgender Alaskans undergoing gender-affirming treatment.
Applying For Marketplace Coverage
When you apply for Marketplace coverage as a transgender person, you should use the first, middle, and last name that are on your Social Security card.
Know Your Rights In Health Care
Federal and state laws – and, in many cases, the U.S. Constitution – prohibit discrimination in health care and insurance because you’re transgender. That means that health plans arent allowed to exclude transition-related care, and health care providers are required to treat you with respect and according to your gender identity.
Is Hormone Therapy For Older Men Included In Insurance Coverage
A universal health plan gives everyone access to health services, medical treatments, and surgical procedures that they will need. In the United States, there are three ways that residents can avail themselves of health insurance: individual plans, employer-sponsored health plans, and government-based programs like Medicare and Medicaid.
How to determine if gender affirmation is covered by Medicare?
The best way to determine if your gender affirmation procedure is covered by your Medicare plan is to speak with your doctor directly.
What are the different types of gender affirmation surgeries?
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.
How much does gender affirmation surgery cost?
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.
What is gender dysphoria?
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.
When did the Medicare Appeals Board lift the exclusion on affirmation-related medical care?
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.
What are the laws that determine what benefits insurance companies offer?
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.
Does Medicare Advantage cover hormone therapy?
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.
The Case That Changed It All
Denee Mallon is a 75-year-old transgender Army veteran. Assigned male at birth but identifying as female, she sought gender confirmation surgery in 2012. Medicare denied her request. 4
What Is Transgender Surgery?
Transgender surgery is not one-size-fits-all. One individual’s approach to gender expression may differ from another’s. Surgeries are often grouped into the following categories.
Gender Dysphoria and Medical Necessity
Medicare does not cover any service unless it deems it to be medically necessary. When it comes to gender confirmation surgery, a diagnosis of gender dysphoria is key.
National Coverage Determination vs. Local Coverage Determination
Medicare-covered services fall into two discrete categories, those with a national coverage determination (NCD) and those with a local coverage determination (LCD). The former states that the service is covered for all qualifying Medicare beneficiaries nationwide, while the latter allows decisions to be made on a case-by-case basis.
Requirements for Gender Confirmation Surgery
Medicare has a bare minimum for what is required for coverage of gender confirmation surgery: 5
Summary
Medicare covers medically necessary gender confirmation surgery for the treatment of gender dysphoria. It does not cover cosmetic procedures. Decisions on whether a beneficiary qualifies are made on a case-by-case basis by the local Medicare Administrative Contractor.
A Word From Verywell
Everyone deserves to feel comfortable in their own body. That has not always been easy for transgender people who want but cannot afford expensive gender confirmation surgery.
Does Medicare Cover Hormone Therapy?
If you want gender reassignment surgery to treat gender dysphoria, you must receive hormone therapy in preparation for surgery. This involves modifying your hormone levels so they are aligned with your gender identity.
What Will You Pay for Gender Reassignment Surgery?
Out-of-pocket costs for gender reassignment surgery vary depending on the specific Medicare plan.
Get Started With Medicare
If you’re age 65 or older and thinking about reassignment surgery, the first step is to enroll in Original Medicare or a Medicare Advantage plan with Part D benefits. If you sign up for Original Medicare, make sure you also enroll in a Medicare Part D standalone policy.