If you are a Medicare beneficiary who is also transgender, you may consider gender reassignment or gender affirmation surgery. Unfortunately, these surgeries can be costly.

But the good news is that Medicare can cover some of the most critical gender reassignment surgeries. Let’s take a closer look at how this works.

How does Medicare Handle Gender Reassignment Surgery?

There have been two developments in recent years concerning Medicare and gender affirmation surgery. Previously, Medicare would not cover these surgeries because of their experimental nature. The Centers for Medicare & Medicaid Services (CMS) removed the experimental designation for gender affirmation surgery in 2014.

In 2016, the CMS determined that coverage for some sex reassignment surgery is possible on a case-by-case basis. Suppose you and your health care providers feel that reassignment surgery is right for you. In that case, you may plead your case with a Medicare Administrative Contractor at your local CMS Office.

Which procedures will Original Medicare cover?

For starters, Medicare will usually not pay for cosmetic procedures associated with alleviating gender dysphoria (formerly known as gender identity disorder). Cosmetic procedures may include, but are not limited to:

  • Facial feminization surgery
  • Hair removal
  • Adam’s Apple reduction
  • Rhinoplasty
  • Fillers or injections designed to contour your face to your identified gender
  • Shaving down your jaw bone or chin

Medicare may approve procedures on a case-by-case basis, including top surgery and bottom surgery. Depending on which gender you identify with, your top surgery may involve:

  • A breast reduction or a mastectomy
  • Breast implants

Bottom Surgery

Bottom surgery may be a complicated, multi-step process. Again, this largely depends on your identifying gender. The most commonly-approved bottom surgeries are:

  • Orchiectomy — surgical removal of the testicles and scrotum
  • Penectomy — surgical removal of the penis
  • Hysterectomy — surgical removal of the uterus
  • Oophorectomy — surgical removal of the ovaries
  • Vaginoplasty — surgical construction of a clitoris and vaginal canal from the tissues of the penis and scrotum
  • Vulvoplasty — construction of the labia majora and minora from penile and/or scrotal tissue
  • Phalloplasty — surgical construction of a penis

Top and bottom surgeries are all performed under general anesthesia in an inpatient hospital setting. You may require at least a few days of recovery time after surgery before you can be discharged and sent home. Because Medicare Part A covers your hospital benefits, you will be responsible for the following costs:

  • Your $1,600 Medicare Part A deductible
  • Any additional blood transfusions after the first 3 pints
  • If you are past day 60 of your current benefit period, you will be subject to a daily coinsurance fee of [GCBB#part-a-inpatient-coinsurance-days-61-90]
  • After day 90 of your current benefit period, your coinsurance fee will be [GCBB#part-a-inpatient-coinsurance-days-91-120] per day until you exhaust your lifetime reserve days
  • After that, all of your hospital costs will be 100% out-of-pocket

Any outpatient medical services you require as a part of your Medicare-approved gender transition will be covered by Medicare Part B.

Suppose you are relying on Original Medicare only. In that case, you will be responsible for your $226 Part B deductible and your 20% coinsurance for the Medicare-approved cost of your care (Medicare will pay the other 80%).

Will Medicare Advantage plans cover gender affirmation surgery?

It depends. These private health insurance plans allow them to set their own rules. But they are also legally mandated by the government to offer at least the same benefits as Original Medicare. It’s best to get in touch with your Medicare Advantage plan provider and ask them directly what is and is not covered.

Will Medicare Supplement Insurance helps cover the costs of gender reassignment surgery?

Medigap policies will help cover these costs if Medicare approves your procedure. Depending on your plan, your benefits could cover some, most, or all of the following expenses:

  • Your Medicare Part A deductible
  • Your Medicare Part B deductible
  • Blood transfusions after 3 pints
  • Your Medicare Part A coinsurance
  • Your Medicare Part B coinsurance
  • Your Medicare Part B excess charges

FAQs

Does Medicare cover reassignment surgery?

As of August 30, 2016, the Center for Medicare and Medicaid Services (CMS) has declined to make a National Coverage Determination specifically on gender reassignment surgery for trans people.

If you and your physician believe gender reassignment surgery is necessary due to gender dysmorphia, you must make your case with your local Medicare Administrative Contractor (MAC). The approval or denial for gender reassignment surgery occurs on a case-by-case basis.

How do you qualify for gender reassignment surgery?

You and your health care providers must make a case with your local CMS office and Medicare Administrative Contractor to prove that your gender confirmation surgery is medically necessary.

If you get a denial for the surgery, you can file an appeal (you should consider legal counsel before doing so).

How much does a gender switch surgery cost?

Gender reassignment surgery can cost around $25,000 for bottom surgery (such as vaginoplasty). Top surgeries (such as breast augmentation) can cost as much as $10,000.

Body contouring and facial surgery to affirm gender identity can also cost thousands if not tens of thousands of dollars but are unlikely to be covered by Medicare.

Does Medicare cover gender reassignment surgery?

Suppose you and your health care providers can prove that your gender dysphoria is causing such an adverse health outcome that gender reassignment surgery is the only way to improve your quality of life.

In that case, you may be able to get the government to cover it via Medicare or Medicaid.

How long does the surgery take?

The average gender reassignment surgery takes about three hours, but some can be as little as two hours or as long as five hours.

Remember that most clinicians will require you to live as your identified gender and undergo hormone therapy for at least one year before you qualify for surgery.

What is the process for getting a sex change?

Most insurance plans (Medicare included) will require transgender individuals to live as their identified gender and undergo hormone replacement therapy for at least one year.

Transgender patients must submit specific documentation, such as health records, that establish a consistent history of gender dysphoria. In addition, they must provide a letter of support from a qualifying social worker, psychiatrist, or other mental health providers.

What are the different types of gender reassignment surgery?

Some of the most common gender reassignment surgeries involve removing sex organs like ovaries, testicles, and genitals. It is not uncommon for these additional surgeries to follow gender-affirming genitoplasty.

There may also be cosmetic procedures to augment the chest, Adam’s apple, and facial features to conform to one’s identified gender.

How are the surgeries performed?

Each surgery is its own specific and unique procedure. If you want more details on the gender-affirming surgeries you require, it’s best to sit down with your doctor and ask questions.

Many of these surgeries are several hours long, require a brief inpatient hospital stay, and occur under general anesthesia.

How to Get Affordable Transgender Surgery with Medicare

Suppose you can successfully prove that your gender affirmation surgery is necessary. In that case, the next step is to make sure you purchase a Medicare supplement that covers the gaps in your Medicare coverage.

We are intimately familiar with providers in your area who will give you the best Medigap plan at a fair monthly rate. Our licensed insurance agents offer their time to you for free, so you can get all the information you need without worrying.

So give us a call today. Or fill out our online request form to be connected with the best rates in your area.

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by Lindsay Malzone, Lindsay Malzone is the Medicare editor for Medigap.com. She's been contributing to many well-known publications since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.