For MTF or MTN, vaginoplasty and penile inversion techniques are used to construct a sensate vagina. Medicare covers all the surgeries listed above (and more) when medically necessary, except for breast augmentation for MTF or MTN individuals. This is because breast augmentation is generally considered a cosmetic procedure.
Full Answer
What do Medicare health plans cover?
Aug 30, 2021 · 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. The definition used by Medicare aligns with the Diagnostic and Statistical Manual of Mental Disorders.
Does Medicare cover transgender surgery?
Jul 07, 2020 · Medicare should cover hormone therapy, gender affirmation surgery, and counseling if your doctor classifies it as medically necessary for your situation. Hormone therapy Hormone therapy can be...
Does Medicare cover transition-related care?
Mandatory benefits include services including inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others. Optional benefits include services including prescription drugs, case management, physical therapy, and occupational therapy.
Does Medicare cover facial feminization surgery?
Medicare and Medicaid Both cover DME equipment. Tho what and how they cover stuff depends on the state and what not that u live and reside n. So short answer is yes. with Medicare there is and or can be 20% co-pay. with Medicaid there will be little or no co-pay.
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.
Is gender affirmation surgery covered by Medicare?
If you are hospitalized for a gender affirmation surgery, you will be covered under Medicare Part A. This coverage also extends to other services you might need while hospitalized, such as nursing care, physical therapy, and certain medications.
Does Medicare cover gender dysphoria?
Medicare covers both inpatient and intensive outpatient mental health therapy. Medicare will also cover therapy for transgender individuals who have already undergone affirmation surgery and need additional support.
How long does it take to appeal a Medicare plan?
For Medicare Advantage plans, you must go directly through your plan provider to appeal. Your Medicare Advantage plan then has 30 to 60 calendar days to respond to your appeal. If you disagree with the decision made after your first appeal, you can appeal up to four more times before a final decision is made.
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.
What is gender affirmation surgery?
Gender affirmation surgery is a group of surgical procedures that allow trans people to transition their physical appearance so that it better represents their gender identity.
What is top surgery?
There are multiple types of top surgeries, depending on your desired results. For FTM or FTN, top surgery involves removing breast tissue and flattening the chest. For MTF or MTN, it involves using breast augmentation to increase the size of the breasts. Bottom surgeries.
Is breast augmentation a cosmetic procedure?
This is because breast augmentation is generally considered a cosmetic procedure . Additional procedures, such as laser hair removal, tracheal shave surgery, and facial feminization surgery, may also be performed as part of your gender affirmation.
Is facial feminization surgery covered by Medicare?
Coverage for Facial Feminization Surgery. If Medicare classifies a facial feminization procedure as an elective cosmetic surgery, it is unlikely to be covered.
Is breast reconstruction covered by Medicare?
Additionally, breast reconstruction following the mastectomy of a breast cancer patient is covered.
What is Medicare Part A?
Medicare Part A (hospital insurance) covers inpatient care in a hospital, skilled nursing facility and religious non-medical health care institution.
What is facial feminization surgery?
Facial feminization surgery (FFS) is undertaken to reconstruct masculine facial features to present a feminine form. The objective is to soften the facial aspects that are commonly considered masculine such as the nasal shape and bone structure. Soft tissue in the face or neck may also be altered.
What is the objective of facial surgery?
The objective is to soften the facial aspects that are commonly considered masculine such as the nasal shape and bone structure. Soft tissue in the face or neck may also be altered. Before you schedule any type of surgery, ask your doctor if it will be an inpatient or outpatient procedure.
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 appearance and functional abilities of the gender they know themselves to be.”
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. However, gender reassignment surgeries were considered “experimental” and were banned by Medicare in 1981.
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 of incisions, nerve injury and hematoma. There also risks associated with specific surgeries, such as injury to the urinary tract for transfeminine bottom surgeries.
What is Medicaid managed care?
Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for these services . By contracting with various types of MCOs to deliver Medicaid ...
What is managed care?
Managed Care is a health care delivery system organized to manage cost, utilization, and quality. Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month ...