Individuals considering gender reassignment surgery may have concerns about their accessibility to quality healthcare and coverage if they receive Medicare benefits. 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 of 65 with certain disabilities. When you become eligible for Medicare, you can choose to get your benefits through Original Medicare or a Medicare Advantage (MA) plan. MA plans are offered by private insurance companies but are required to provide at least the same coverage as Original Medicare Part A and Part B.
Most people qualify for Part A (Hospital Insurance) automatically, but many enroll in Part B (Medical Insurance) as soon as they are eligible to receive important healthcare coverage for doctor visits, preventive care, and more, without incurring any penalty fees for enrolling later. All eligible Medicare recipients are covered for benefits regardless of their gender. Due to certain services and supplies being categorized as appropriate for one gender or another, initial coverage may be denied if your current gender does not match your original Social Security records. If you are denied coverage for gender-specific services, such as mammograms, pelvic exams, or prostate exams, you can appeal. The Centers for Medicare & Medicaid Services (CMS) has procedures in place to address these claims and special billing codes to assist medical providers in providing appropriate services based on individual needs and necessary care.
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. 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.
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.”
Medicare Part D: Medicare Prescription Drug Coverage