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.
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:
- 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.
- 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%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Gender reassignment surgery is usually the last step in the process of changing from one sex to the other. The surgery can help a person with gender dysphoria transition to their desired gender.
The process usually begins with talk therapy to determine if a person is ready to go through a permanent physical change. Following that decision, the next phase involves hormone therapy. Biological men take estrogen and biological females take androgens (male hormones).
The purpose of hormone therapy is to change a person’s physical appearance. For example, females who take androgens may develop facial hair, while males who take estrogen may experience female traits such as weight redistribution and changes in the skin.
There can be complications from therapy:
Doctors may ask a person to take on the role of the desired sex, socially and professionally, for up to a year before surgery.
Surgery is the final step in gender reassignment. It may take several surgeries to complete the change from a male to female or from a female to male.
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.
Surgeries may include several steps, depending on the desired gender changes.
Biological female to male
- mastectomy or breast reduction
- nipple graft
- removal of the uterus and ovaries
- closure of the vagina
- creation of a penis and scrotum
- extension of the urethra through the penis, via a tube from the bladder to the outside of the body
- penile implant
- synthetic testicles
- voice surgery
Biological male to female
- facial feminization
- nose surgery
- eyebrow lift
- jaw surgery
- chin reduction
- enhancement of cheekbones
- lip lift
- female hairline
- laser hair removal
- hair reconstruction
- voice change
- reduction of the Adam’s apple
- breast augmentation
- removal of penis and scrotum
- creation of vagina, clitoris, and labia
There may be complications from surgery, including bleeding, infection, and side effects from anesthesia.
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.
However, the Centers for Medicare & Medicaid Services (CMS) has not created a national policy, which means a person’s plans will decide if the surgery is medically necessary. This online tool will help a person find more information about their local state policies.
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.
However, because there is no nationwide policy on access to gender reassignment surgery, a person’s Medicare Advantage plan can decide if surgery is necessary and reasonable.
To find out if coverage is available, a person can check with their plan, use the Medicare online tool.
Medicare Part D pays for hormone therapy. However, if a person does not have Medicare Part D or Medicare Advantage, they may have to pay for prescription medications themselves.
People who are aged 65 and older can enroll in Medicare. Some younger people with disabilities or end stage renal disease also can get Medicare. People can enroll online through Social Security or at their local Social Security office.
There are various times during the year when a person can enroll in Medicare:
- The Initial Enrollment Period (IEP) starts 3 months before the month of a person’s 65 birthday, includes the birth month, and ends 3 months later. There is a total of 7 months in the IEP, including the birth month.
- If a person does not enroll during the IEP, they can sign up during the General Enrollment Period, from January 1 to March 31 every year.
- During the period of October 15 to December 7, a person can drop, join, switch, or change a Medicare drug plan or Advantage plan.
- In some circumstances, called a Special Enrollment Period, a person can make changes to the Medicare drug plans or Advantage plans.
When a person does not sign up for Medicare during the IEP, they may pay a late penalty.
Most people do not pay a premium for Part A. However, if a person does not qualify for premium-free Part A, they may have to buy Part A, which can cost up to $458 per month.
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. 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.
The cost of gender reassignment while on medicare will depend on which surgeries you will need performed and what medications you will be on after surgery. You will likely pay the $1408 Medicare Part A deductible for the some of the major surgeries, but will also pay the Part B deductible and 20% coinsurance on any outpatient procedures.
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.
A person must pay the same premiums and deductibles as they would for other surgeries or medical treatments.
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