Along with hormone therapy, you must also receive counseling before Medicare approves the surgery. Typically, you have to complete at least 12 months of continuous hormone therapy to be eligible, as well as provide confirmation of a gender dysphoria diagnosis.
Full Answer
Does Medicare cover gender reassignment surgery?
Also, your doctor must confirm that the operation is necessary. You may have to show counseling and hormone therapy before coverage approval. Medicare covers necessary surgery to change primary sex characteristics from one gender to the other. Medicare Part B covers outpatient services.
What is Medicare prior authorization?
Prior authorization is a requirement that a health care provider obtain approval from Medicare to provide a given service. Prior Authorization is about cost-savings, not care. Under Prior Authorization, benefits are only paid if the medical care has been pre-approved by Medicare. Private, for-profit plans often require Prior Authorization.
Does Medicare require prior authorization to buy medical equipment?
Medicare, including Part A, rarely requires prior authorization. If it does, you can obtain the forms to send to Medicare from your hospital or doctor. The list mostly includes durable hospital equipment and prosthetics. Medicare Part B Prior Authorization
What services require prior approval from Medicare Advantage?
The services most often requiring prior approval are durable medical equipment, skilled nursing facility stays, and Part B drugs. But, each Advantage plan is different. If you have an Advantage plan, contact your plan provider to determine if or when prior authorization is necessary.
Does Medicare cover gender affirming surgery?
Medicare covers gender affirmation procedures when they're deemed medically necessary. Procedures covered by Medicare may include hormone therapy, gender affirmation surgeries, and counseling before and after surgery.
Does Medicare cover gender reassignment surgery 2022?
Medicare pays for gender reassignment surgeries and hormone replacement therapy, as long as the surgery is deemed medically necessary. There are several surgeries a person needs to finish the process. Medicare Advantage plans may apply different rules when considering approval for surgeries.
How do you pay for gender reassignment surgery?
Consider these options to pay for gender-affirming surgery and care:Online personal loan.Credit union personal loan.Credit card.CareCredit.Home equity line of credit.Family loan.
Does Medicare cover transition surgery?
All Medicare beneficiaries have a right to access prescription drugs that are appropriate to their medical needs. Medicare covers medically necessary transition-related surgery.
How much does male to female surgery cost?
The information that is available on costs of sex reassignment surgery indicates that in the United States male to female surgery can cost between $10,000 and $28,000 (U.S.).
How long does it take to transition from female to male?
Some of the physical changes begin in as little as a month, though it may take as long as 5 years to see the maximum effect.
Is gender reassignment covered by insurance?
Many health plans are still using exclusions such as “services related to sex change” or “sex reassignment surgery” to deny coverage to transgender people for certain health care services.
How much does MTF top surgery cost?
The average cost range for MTF and MTN top surgery varies greatly depending on factors such as body size, body shape, and desired breast size. The average cost range for this surgery is between $5,000 and $10,000. There's typically a hospital or facility fee and anesthesiologist fee added to the total bill.
How do people afford facial feminization surgery?
Utilizing coverage under a health insurance plan is often the most affordable way to pay for FFS. And some health insurance plans do cover the costs associated with facial feminization surgery procedures, so we recommend contacting your insurance provider to find out what is and is not covered under your current plan.
Is gender reassignment surgery legal in the US?
No states have enacted a blanket ban on gender reassignment treatment for transgender minors.
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.
Can you surgically change your gender?
Gender-affirming surgery gives transgender people a body that aligns with their gender. It may involve procedures on the face, chest or genitalia. Common transgender surgery options include: Facial reconstructive surgery to make facial features more masculine or feminine.
What does prior authorization mean?
Prior authorization means your doctor must get approval before providing a service or prescribing a medication. Now, when it comes to Advantage and Part D, coverage is often plan-specific. Meaning, you should contact your plan directly to confirm coverage.
Does Medicare require prior authorization?
Medicare Part A Prior Authorization. Medicare, including Part A, rarely requires prior authorization. If it does, you can obtain the forms to send to Medicare from your hospital or doctor. The list mostly includes durable hospital equipment and prosthetics.
Do you need prior authorization for Medicare Part B?
Part B covers the administration of certain drugs when given in an outpatient setting. As part of Medicare, you’ll rarely need to obtain prior authorization. Although, some meds may require your doctor to submit a Part B Drug Prior Authorization Request Form. Your doctor will provide this form.
Does Medicare Advantage cover out of network care?
Unfortunately, if Medicare doesn’t approve the request, the Advantage plan typically doesn’t cover any costs, leaving the full cost to you.
Does Medicare cover CT scans?
If your CT scan is medically necessary and the provider (s) accept (s) Medicare assignment, Part B will cover it. Again, you might need prior authorization to see an out-of-network doctor if you have an Advantage plan.
What is gender confirmation surgery?
Gender confirmation surgery is an umbrella term for any surgery that transgender or gender-nonconforming people use to align their bodies to their gender identity. Gender confirmation surgery is also known by a number of other names including gender alignment surgery, gender affirmation surgery, gender reassignment surgery, and sex change surgery.
What is gender reassignment surgery?
Gender reassignment surgery implies that the surgery is changing someone's gender when it is actually aligning the body to the person's gender. Sex change surgery is somewhat antiquated as a term. It comes with a problematic history. However, all of these terms are used in various contexts.
What percentage of transgender women wanted breast augmentation?
A large national survey of transgender individuals found that: 66% of transgender women either had or wanted vaginoplasty or labiaplasty. 51% of transgender women either had or wanted breast augmentation. 50% of transgender women either had or wanted facial feminization.
How to show that a person has a gender dysphoria?
Showing that a person has "persistent, well-documented gender dysphoria" usually requires a letter from a mental health provider stating that the person meets the criteria for gender dysphoria and the length of time for which that has been true. This letter often also contains a narrative of the patient's gender history—in varying degrees of detail. In addition, the letter should state how long the provider has been working with the patient.
Do transgender people want surgery?
Not all transgender, non-binary, and genderqueer individuals want surgery to align their bodies to their gender identity. Some individuals are content with social or medical transition options. Others want one or more surgeries, but may or may not have access to them. A large national survey of transgender individuals found that:
Is facial feminization surgery covered by insurance?
There are no formal guidelines for facial feminization surgery. It has historically been very difficult to get this procedure covered by insurance, due to a lack of research on the benefits. However, some individuals have been able to have it successfully covered by arguing that it is as medically necessary as genital surgery and has equally positive effects on quality of life.
Can gender affirmation surgery be done for mental health?
Of note, mental health conditions are not a contraindication for gender affirmation surgeries. In fact, these procedures can help resolve symptoms in many transgender people and others with gender dysphoria. This is true not just for anxiety and depression but for more serious conditions such as psychosis.
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.
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.
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 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.
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.
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.
Does Medicare cover shave surgery?
But these surgeries are generally considered cosmetic in nature, so Medicare doesn’t cover them.
What is the goal of a gender surgery?
The goal of the surgery is to give the person the appearance and function of the desired gender. To achieve that goal, a person may need to go through several surgeries. As such, the surgical team often includes a plastic surgeon, urologist, gynecologist, and an ear, nose, and throat specialist.
What is Medicare Advantage?
Medicare Advantage. Medicare Advantage (Part C) plans are sold by private companies. They combine the benefits of original Medicare parts A and B. Some plans also pay for medications. In general, Advantage plans provide the same coverage as original Medicare, parts A and B.
How much is deductible for Medicare Advantage?
If a person goes into hospital, there is a $1,408 deductible for every benefit period. There is no coinsurance if a person is discharged within 60 days. Premiums for Medicare Advantage plans or Part D plans vary depending on the company providing the plans. An online tool can help people find and compare plan costs.
How much is Medicare Part B 2020?
The standard premium for Medicare Part B in 2020 is $144.60 each month, and there is a $198 annual deductible cost. After a person pays the deductible, Medicare pays 80% of the allowable costs. The coinsurance is 20% of the charges. If a person goes into hospital, there is a $1,408 deductible for every benefit period.
What is the best Medicare plan?
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan: 1 Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments. 2 Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%. 3 Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
How long does Medicare enrollment last?
There is a total of 7 months in the IEP, including the birth month.
Is Medicare coverage nationwide?
While Medicare coverage is nationwide, there may be state variations in policies and guidelines. In this article, we discuss gender reassignment surgeries, Medicare coverage, enrollment, and costs. We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
What is prior authorization in Medicare?
Medicare Prior Authorization. Prior authorization is a requirement that a health care provider obtain approval from Medicare to provide a given service. Prior Authorization is about cost-savings, not care. Under Prior Authorization, benefits are only paid if the medical care has been pre-approved by Medicare.
Do Medicare Advantage plans require prior authorization?
Private, for-profit plans often require Prior Authorization. Medicare Advantage (MA) plans also often require prior authorization to see specialists, get out-of-network care, get non-emergency hospital care, and more.
Medical Transition Care Options and Average Costs
Medical transition care options are diverse in terms of procedures, costs and outcomes. Each transgender person, along with their medical provider, should choose the options that make the most sense in terms of budget and desired results.
What Health Insurance Can Cover
In the U.S., it is illegal for most public and private health insurance providers to discriminate against transgender patients or deny them transition-related care. However, trans patients may still face financial and logistical barriers. Here’s what you should know about health insurance coverage and gender confirmation surgery.
Ways to Navigate Health Insurance for Gender-Confirming Surgeries
It can be challenging to navigate health insurance coverage for gender confirmation surgery, but it’s not impossible. It’s important to know your rights as a patient when interacting with providers and finding the best health insurance plan for your needs. Here are some tips to keep in mind.
Financing Options and Support
Outside of partial or full health insurance coverage, there are several other options for financing gender confirmation surgery, such as loans, lines of credit, grants and scholarships and fundraising.
Advocacy Organizations Making a Change
Many LGBTQ advocacy organizations are making a difference in the lives of transgender and gender non-conforming people every day. Here are just a few of the LGBTQ charities, nonprofits and other organizations making positive changes.
Expert Insight on Financing Gender Confirming Surgery
What steps should trans, nonbinary and gender non-conforming employees take when navigating health insurance coverage for gender confirmation surgery?
Additional Resources for Trans-Related Healthcare and Support
If you are a transgender or gender non-conforming patient seeking funding or support for your gender confirmation surgery, various resources can help. Here are some of the best resources available for trans people, loved ones and allies who want to know more about gender confirmation surgery.
What is the CMS 1736-FC?
As part of the Calendar Year 2021 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS-1736-FC), CMS is adding Implanted Spinal Neurostimulators and Cervical Fusion with Disc Removal to the nationwide prior authorization process for hospital outpatient department (OPD) services, effective July 1, 2021. These two services will be in addition to the existing list of services requiring prior authorization, which include blepharoplasty, botulinum toxin injection, rhinoplasty, panniculectomy, and vein ablation.
What is the HCPCS code for ear cartilage grafting?
CMS is removing HCPCS code 21235 (Obtaining ear cartilage for grafting) from the list of codes that require prior authorization as a condition of payment, because it is more commonly associated with procedures unrelated to rhinoplasty that are not likely to be cosmetic in nature. The updated list of codes that require prior authorization as a condition of payment can be found below.
When will OPDs receive notice of exemption?
Hospital OPD providers who met the affirmation rate threshold of 90% or greater will receive a written Notice of Exemption no later than March 1, 2021. Those hospital OPDs will be exempt from submitting prior authorization requests for dates of service beginning May 1, 2021.
What is CMS in Medicare?
The Centers for Medicare & Medicaid Services (CMS) runs a variety of programs that support efforts to safeguard beneficiaries’ access to medically necessary items and services while reducing improper Medicare billing and payments. Through prior authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules.
What is pre claim review?
Under pre-claim review, the provider or supplier submits the pre-claim review request and receives the decision prior to claim submission; however, the provider or supplier can render services before submitting the request. A provider or supplier submits either the prior authorization request or pre-claim review request with all supporting medical ...