Does Medicare cover gender reassignment surgery?
Now Medicare Administrative Contractors determine coverage of gender reassignment surgery on an individual claim basis. That means Medicare may cover gender reassignment surgery for Medicare beneficiaries with gender dysphoria whose doctors and health care providers determine there is a medical necessity for the surgery.
What are the different types of gender reassignment surgery?
For male to female gender reassignment surgeries there are three categories: Facial feminization surgery to transform masculine features of the face into a more feminine appearance Transfeminine bottom surgery to transform male genitalia and reconstruct it into that of a female.
How does gender matching affect my Medicare claim?
Medicare and insurers often have a computer-matching program that only allows services to be paid for if the gender "marker matches," as a means of preventing mistakes and fraud in billing. This has the unintended consequence of denying claims for procedures that many transgender people need.
How many transgender people are on Medicare?
Today, more than 1.4 million people identify as transgender, 1 and more than 10,200 of them are on Medicare. 2 While many people tend to think of Medicare as health care for people over 65, they forget that Medicare also covers younger people with qualifying disabilities.
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.
Does Medicare cover gender reassignment surgery 2022?
Medicare covers necessary gender reassignment surgery. It also pays for doctor visits and lab work as you go through the transition process. Also, prescription plans usually cover hormone treatments for transgender people.
How much does gender reassignment surgery cost in the US?
Gender reassignment surgeries are expensive. Bottom surgeries can cost about $25,000 and top (breast surgeries) from $7,800 to $10,000. Facial and body contouring are also costly. More employer insurance policies, and those sold under the Affordable Care Act, now cover at least some gender reassignment surgeries.
How do you qualify for gender reassignment surgery?
patients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity.patients reach the legal age of majority in a given country, and.patients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity.
How do you pay for gender reassignment surgery?
Transgender Americans can pay a steep price if gender confirmation surgery is part of their transition....Consider these options to pay for transgender surgery:Online personal loan.Credit union personal loan.Credit card.CareCredit.Home equity line of credit.Family loan.
Does Medicare cover hormone therapy?
Medicare covers medically necessary hormone therapy. These medications are part of Medicare Part D lists of covered medications and should be covered when prescribed. Private Medicare plans should provide coverage for these prescriptions.
How much is bottom surgery in Texas?
How much does bottom surgery cost?SurgeryCost runs from:vaginoplasty$10,000-$30,000metoidioplasty$6,000-$30,000phalloplasty$20,000-$50,000, or even as high as $150,000May 10, 2018
How much is MTF top surgery?
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 much is bottom surgery for female to male?
For patients not covered by health insurance, the typical cost of a sex reassignment surgery can range from about $15,000 for just reconstruction of the genitals to about $25,000 for operations on the genitals and chest to $50,000 or more for procedures that include operations to make facial features more masculine or ...
How long does a male to female transition take?
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. For example, men transitioning to women can expect A-cup and occasionally larger breasts to fully grow within 2 to 3 years.
Do you have to be diagnosed with gender dysphoria to get surgery?
Many insurance companies require you to submit specific documentation before they will cover a gender-affirming surgery. This documentation includes: Health records that show consistent gender dysphoria. Letter of support from a mental health provider, such as a social worker or psychiatrist.
At what age can you change your gender?
Gender reassignment surgery is widely restricted to adults over the age of 18.
What Is Gender Reassignment Surgery?
According to the American Society of Plastic Surgeons, that goal of gender reassignment surgery is “to give transgender individuals the physical ap...
Does Medicare Cover Gender Reassignment Surgery?
Sir Harold Gillies performed the first female to male gender reassignment surgery in 1946, according to the U.S. National Library of Medicine. Howe...
Who Can Get Gender Reassignment Surgery?
According to the American Society of Plastic Surgeons (ASPS), gender reassignment surgeries have risks, such as bleeding, infection, poor healing o...
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.
How long does Medicare enrollment last?
There is a total of 7 months in the IEP, including the birth month.
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.
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.
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:
Does Medicare cover cosmetic surgery?
Medicare coverage. Medicare does not cover what they rule as cosmetic surgery, and until 2014, did not cover surgeries to change gender. The rule was changed to include surgeries for medical reasons, which includes gender reassignment.
Description Information
Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.
National Coverage Analyses (NCAs)
This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.
Do you need to get preauthorization for a transition surgery?
The National Center for Transgender Equality recommends that you get pre-authorization from your Advantage plan before you get healthcare related to your transition. Also, unlike Medicare, Advantage plans rely on networks.
Does Medicare pay for breast removal surgery?
Medicare Part B covers outpatient services. If you’re hospitalized for your surgery, Part A pays for it. With Medicare, you can see any doctor that accepts Medicare.
Does Medicare pay for gender dysphoria surgery?
For Medicare to pay for your surgery, your doctor must diagnose you with gender dysphoria or gender identity disorder. Also, your doctor must confirm that the operation is necessary. You may have to show counseling and hormone therapy before coverage approval.
Does Medicare cover gender reassignment surgery?
Medicare covers necessary gender reassignment surgery. It also pays for doctor visits and lab work as you go through the transition process. Also, prescription plans usually cover hormone treatments for transgender people. Yet, Medicare won’t pay for surgery to make your physical features more masculine or feminine.
Can you have gender reassignment surgery with Medicare?
Gender reassignment surgery is a special procedure, and you’ll want to choose an expert healthcare team. But if you only have Medicare, your costs can be high. A Medigap plan can make gender reassignment surgery more affordable. Let the experts at MedicareFAQ help you find the right Medigap plan for your needs.
Does Medicare cover facial feminization?
But, Medicare won’t pay to change a person’s appearance because Medicare considers it cosmetic and not considered medically necessary. So, this means Medicare won’t cover facial feminization, breast augmentation, hair removal, face or body contouring, or vocal cord surgeries.
Does Medicare cover Part B deductible?
If Medicare covers, then your plan will too. But, if Medicare denies your claim, Medigap won’t pay it either. For example, if you have Plan G, you pay your premium and the Part B deductible. Then, the plan covers the charges Medicare would’ve sent you.
Does Medicare cover hormone therapy?
Hormone Therapy. In preparation for gender reassignment surgery, Medicare will cover hormone therapy through Part D prescription drug coverage. If you have Original Medicare, you will need to be enrolled in a stand-alone Prescription Drug Plan (PDP). Many Medicare Advantage plans include prescription drug coverage.
Does Medicare cover transgender people?
Routine preventive care and transition-related services are vitally important to prepare for gender reassignment surgery, but there can be some confusion about Medicare coverage for transgender individuals. Medicare is a federal program that provides health insurance for individuals 65 years of age or older, and some people under the age ...
Does Medicare Advantage cover prescriptions?
Many Medicare Advantage plans include prescription drug coverage. If coverage is initially denied due to inconsistency with Social Security gender records, an appeal can be made to provide a Medicare recipient with access to medications they require to meet their specific needs.
Does Medicare cover gender reassignment surgery?
The Centers for Medicare & Medicaid Services has not issued a national coverage determination on gender reassignment surgery, and therefore, leaves coverage determination up to local Medicare Administrative Contractors (MACs). According to CMS, coverage will be based on whether the surgery is considered “reasonable and necessary for the individual beneficiary after considering the individual’s specific circumstances. For Medicare beneficiaries enrolled in Medicare Advantage (MA) plans, the initial determination of whether or not surgery is reasonable and necessary will be made by the MA plans.”
What Is Gender Dysphoria?
Gender dysphoria is a clinical diagnosis often given to individuals who experience distress or discomfort because their gender identity doesn’t match their sex-related physical characteristics.
What Is Gender Reassignment Surgery?
Gender reassignment surgery, which is sometimes referred to as sex reassignment surgery or gender affirmation surgery, is part of the process of physically transitioning from one gender to the other. The surgery may involve more than one procedure, and it typically follows other transitional steps such as counseling and hormone replacement surgery.
Is Gender Reassignment Surgery Medically Necessary?
Gender reassignment surgery may be considered medically necessary to treat anxiety and depression related to body dysphoria.
Does Medicare Cover Gender Reassignment Surgery?
Medicare covers the costs of gender reassignment surgery if it’s considered medically necessary. Surgery may be deemed medical necessary to treat mental health issues related to a gender dysphoria diagnosis or simply because an individual demonstrates a committed desire to transition.
Does Coverage for Gender Reassignment Surgery Vary by State?
Although Medicare is a federally regulated program, state laws may impact Medicare's decision to cover gender reassignment surgery. Information on state health care laws and policies that may affect coverage for transgender-related medical care can be found by visiting the Movement Advancement Project .
What Is Hormone Therapy?
Hormone therapy is a medical treatment that adjusts an individual's hormone levels so they align with their gender identity. Individuals who wish to undergo gender reassignment surgery must typically undergo hormone therapy for a year or more prior in order to be approved for the procedure.
Does Medicare Cover Hormone Therapy?
Medicare covers the cost of hormone therapy through its Part D prescription drug plan or any Medicare Advantage plan that bundles in prescription drug coverage. The therapy must be deemed medically necessary.
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.
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.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
Gender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5™ as a condition characterized by the "distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender" also known as “natal gender”, which is the individual’s sex determined at birth.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
Why did Medicare order a transgender woman to have surgery?
For example, in 2015 the Medicare Appeals Council issued a decision ordering a Medicare plan to pay for transition-related surgery for a transgender woman because it was reasonable and necessary to treat gender dysphoria.
What is the Medicare billing code for a pap smear?
The Medicare manual has a specific billing code (condition code 45 ) to assist processing of claims under original Medicare (Parts A and B).
Does Medicare cover transgender people?
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, ...
Does Medicare cover transition surgery?
Medicare covers medically necessary transition-related surgery. For many years, Medicare did not cover transition-related surgery due to a decades-old policy that categorized such treatment as "experimental.". That exclusion was eliminated in 2014, and there is now no national exclusion for transition-related health care under Medicare.
Does Medicare use gender data?
Your Medicare insurance records will typically be based on Social Security data. To learn more about updating your name and gender marker with Social Security, check out our ID Documents center. As a reminder, the gender marker you have in the Medicare record system should not impact access to care.
Is there a national exclusion for transition related care?
That exclusion was eliminated in 2014, and there is now no national exclusion for transition-related health care under Medicare. In practice, this means coverage for transition-related care will be decided on a case-by-case basis, no different than how Medicare handles coverage for most other medical treatments.
Does Medicare cover hormone therapy?
Medicare covers medically necessary hormone therapy . Medicare also covers medically necessary hormone therapy for transgender people. These medications are part of Medicare Part D lists of covered medications and should be covered when prescribed. Private Medicare plans should provide coverage for these prescriptions.