Many trans people undergo some form of medical transition to help align their external characteristics with their gender identity. For some folks, this includes gender-affirmation surgery, which can be seen as a necessary step in the transition process.
If you or someone you care for is being treated for gender dysphoria and considering gender-affirming surgery, here’s what you should know about your coverage under Medicare.
What is Gender-Affirming Surgery?
Gender-Affirming Surgery or Gender Confirmation Surgery (GCS) is an umbrella term that covers the surgical procedures that help people suffering from gender dysphoria achieve the outward physical appearance that matches their internal gender.
GCS is actually a series of surgical procedures. These are usually broken into “top” surgeries and “bottom” surgeries.
- “Top” surgeries include breast removal and reshaping of existing tissue to create a more masculine silhouette for female-to-male transitions, and breast augmentation for male-to-female transitions.
- “Bottom” surgeries include removal of the ovaries, uterus, and vagina, and genital reconstruction with penile and scrotal implants in female-to-male transitions. They also include removal of the penis, scrotum, and prostate gland with genital reconstruction to create a vagina, labia, and clitoris in male-to-female transitions.
The decision to have surgery is highly personal and not everyone who has GCS chooses to have all of the “top” and “bottom” procedures.
Medicare’s Distinction between Medically Necessary and Cosmetic Procedures
While many folks who chose to have GCS to eliminate or decrease dysphoria feel that having surgery is a necessary part of their journey, GCS procedures are treated by insurance companies as either “medically necessary” or “cosmetic.” In most cases, only “medically necessary” surgeries are covered.
In the case of Gender-Affirming surgery, medically necessary procedures are usually limited to those that change primary sex characteristics.
For folks that were assigned female at birth and are transitioning, medically necessary procedures include:
- Removal of breasts, ovaries, and uterus
- Genital reconstruction to create external male genitalia
For folks that were assigned male at birth and are transitioning, medically necessary procedures include:
- Removal of the penis, testicles, and occasionally the prostate gland
- Genital reconstruction to create female genitalia
There are many surgical procedures that help transgender people more fully achieve the secondary sex characteristics and appearance that match their internal gender.
These procedures may include breast implants, facial contouring, reduction of the size of the nose and chin, vocal cord surgery, hair removal and body contouring procedures, chin and nose implants, lip reduction, and hair transplants. While they may be necessary for you as an individual, procedures that deal with these secondary sex characteristics and appearance are usually considered cosmetic by Medicare and are typically not covered.
How Does Medicare Cover Transgender Surgery?
In 1981, GCS was qualified as an experimental treatment, and excluded for coverage under Medicare. However, in 2014, Medicare changed the rules regarding GCS and now handles cases on an individual basis; they may pay for medically necessary surgery if certain criteria are met.
In most cases, to be covered under Medicare, you must:
- Have well-documented and persistent gender dysphoria
- Have completed at least 12 months of continuous hormone therapy
- Have lived for at least 12 months in the gender role you are transitioning to
- Be free of any serious medical or mental health concerns, or be on appropriate medications to control them
- Have two recommendations from qualified mental health professionals, one of whom is not your regular doctor
If you meet the criteria for GCS, Medicare will help pay for your treatment. You may have to meet your deductible and coinsurance amounts, plus pay any excess charges if your doctors don’t participate with Medicare.
Does Medicare Pay for Other Transgender Care?
Medicare covers medically necessary care for gender dysphoria. Part B covers your visits with your primary care doctor, and specialist care as well as approved surgery. It also covers necessary tests to diagnose and treat your condition. Part A covers any inpatient care you may need.
While Medicare covers much of the costs associated with this care, you are responsible for deductibles and coinsurance. For example, Part B only pays 80% of outpatient care, so you would be responsible for the other 20%. There are Medigap policies available to help you pay for the share that you would normally pay.
If your doctor prescribes hormone therapy for gender dysphoria, Part B covers the routine lab work and doctor visits needed to monitor your response to treatment. It does not, however, cover the cost of the hormones themselves. If you have Part D coverage for prescription drugs, your plan should cover hormone therapy and most other medications. You may have a deductible and copayment amounts specific to your Part D drug plan.
Remember, if Medicare denies a claim for transgender care you believe should be covered, you always have the right to appeal the decision and ask for a redetermination.