If you want gender reassignment surgery to treat gender dysphoria, you must receive hormone therapy in preparation for surgery. This involves modifying your hormone levels so they are aligned with your gender identity. Medicare does cover hormone therapy, but you must have a Medicare Part D prescription drug plan.
Should CMS issue a NCD for surgery for gender dysphoria?
Response: The purpose of this NCA is to determine whether or not CMS should issue a NCD to cover surgery for patients who have gender dysphoria. NCAs do not establish payment amounts or spending priorities and, therefore, these comments are outside the scope of this consideration.
Are there other therapeutic options for gender dysphoria?
Although there are other therapeutic options for gender dysphoria, consistent with the NCA request, this decision only focuses on gender reassignment surgery. B. Prevalence of Transgender Individuals
Does Medicare cover gender reassignment surgery?
Gender reassignment surgery is a general term to describe a surgery or surgeries that affirm a person's gender identity. D. Other The Centers for Medicare & Medicaid Coverage (CMS) conducted a National Coverage Analysis that focused on the topic of gender reassignment surgery.
Does Medicare cover hormone therapy for transgender people?
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.
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.
Does Medicare cover gender affirming care?
Medicare covers gender affirmation procedures when they're deemed medically necessary. Procedures covered by Medicare may include hormone therapy, gender affirmation surgeries, and counseling before and after surgery.
Is gender dysphoria covered by insurance?
A diagnosis of gender dysphoria is required by health insurers before they will cover gender-altering treatments. Gender reassignment surgeries are expensive. Bottom surgeries can cost about $25,000 and top (breast surgeries) from $7,800 to $10,000.
Is gender reassignment surgery covered?
Many health plans are still using exclusions such as “services related to sex change” or “sex reassignment surgery” to deny coverage to transgender people for certain health care services.
Does Medicare cover surgery?
Does Medicare Cover Surgery? Medicare covers surgeries that are deemed medically necessary. This means that procedures like cosmetic surgeries typically aren't covered. Medicare Part A covers inpatient procedures, while Part B covers outpatient procedures.
Is facial feminization surgery covered by Medicare?
Medicare does not cover certain cosmetic surgery procedures, such as laser hair removal and facial feminization surgery, because these are not considered medically necessary.
Does insurance cover FtM bottom surgery?
Bottom Surgery: FtM Vaginectomy and related FtM bottom surgeries including phalloplasty and metoidioplasty were covered by more than 85% of companies (Fig. 9). Similar to penectomies, insurance companies agree that the removal of the genitals, ie, vaginectomy, can treat gender dysphoria.
How can I get my insurance to pay for surgery?
In a nutshell, surgeries are generally covered by health insurance policies but with some terms and conditions. In most cases, they must be 'medically necessary' to be approved by the insurance company when you file for a claim. However, the details of the coverage vary greatly among different policies.
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.
How much does GRS cost?
Sexual reassignment surgery (SRS, or GRS for 'gender') for trans women and trans femme people costs upwards of around $30,000, which many will find a daunting check to write, but the benefits will completely outweigh the costs. Other surgeries such as top surgery will cost between $9000 to $10,000.
How much is FTM top surgery?
The average range for cost of FTM and FTN top surgery is currently between $3,000 and $10,000. 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.
How do you deal with gender dysphoria without transitioning?
Other ways to ease gender dysphoria might include use of:Peer support groups.Voice and communication therapy to develop vocal characteristics matching your experienced or expressed gender.Hair removal or transplantation.Genital tucking.Breast binding.Breast padding.Packing.More items...•
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.
How much does it cost to get top surgery in Australia?
A note on surgery fees Surgeons' costs vary significantly and change all the time, you can expect to pay between $7,000 and $12,000 depending on what (if any) private insurance you have. These costs encompass surgeon fees, hospital fees, anaesthetist fees, and the the surgery itself.
What does condition code 45 mean?
Ambiguous Gender CategoryPolicy: For Part A claims processing, institutional providers shall report condition code 45 (Ambiguous Gender Category) on any outpatient claim related to transgender or hermaphrodite issues.
Is Top surgery considered medically necessary?
Not every person with gender dysphoria has the need to undergo surgery, but for those who do, Top Surgery is medically necessary and has been scientifically proven to be effective at treating gender dysphoria and improving quality of life, in both adults and minors.
Decision Summary
Currently, the local Medicare Administrative Contractors (MACs) determine coverage of gender reassignment surgery on a case-by-case basis. We received a complete, formal request to make a national coverage determination on surgical remedies for gender identity disorder (GID), now known as gender dysphoria.
Decision Memo
Currently, the local Medicare Administrative Contractors (MACs) determine coverage of gender reassignment surgery on a case-by-case basis. We received a complete, formal request to make a national coverage determination on surgical remedies for gender identity disorder (GID), now known as gender dysphoria.
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.
Does Medicare Cover Hormone Therapy?
If you want gender reassignment surgery to treat gender dysphoria, you must receive hormone therapy in preparation for surgery. This involves modifying your hormone levels so they are aligned with your gender identity.
What Will You Pay for Gender Reassignment Surgery?
Out-of-pocket costs for gender reassignment surgery vary depending on the specific Medicare plan.
Get Started With Medicare
If you’re age 65 or older and thinking about reassignment surgery, the first step is to enroll in Original Medicare or a Medicare Advantage plan with Part D benefits. If you sign up for Original Medicare, make sure you also enroll in a Medicare Part D standalone policy.
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.
What is the AAP policy on surgery?
In a 2018 policy statement entitled Ensuring Comprehensive Care and Support for Transgender and Gender- Diverse Children and Adolescents, the AAP states the following regarding surgery: Surgical approaches may be used to feminize or masculinize features, such as hair distribution, chest, or genitalia, and may include removal of internal organs, such as ovaries or the uterus (affecting fertility). These changes are irreversible. Although current protocols typically reserve surgical interventions for adults, they are occasionally pursued during adolescence on a case-by case basis, considering the necessity and benefit to the adolescent’s overall health and often including multidisciplinary input from medical, mental health, and surgical providers as well as from the adolescent and family.
Is ancillary surgery necessary for gender dysphoria?
Certain ancillary procedures may be considered cosmetic and not medically necessary when performed as part of surgical treatment for Gender Dysphoria. Clinical review for medical necessity of ancillary procedures is conducted on a case-by-case basis.